Saturday 26 December 2015

Happy Holidays!

Just a quick post to wish anyone reading a happy holidays. Hope everyone who celebrates it had a good Christmas yesterday and hope that everyone who buys things is enjoying the Boxing Day sales today.

I got an interesting stocking-stuffer gift this year, a pocket medical dictionary from 1928. It's an interesting read! Lots of terms that are no longer in use or which have changed in use in the past century. There's a big focus on herbalism and infectious diseases, since Penicillin was only invented that very year and wasn't used clinically for over a decade afterwards. Heck, there's an entry for Penicillium, the fungus that produces Penicillin, but not the drug itself!

There are also a lot of subtly (or not-so-subtly) racist terms... not cool old docs, not cool.

Anyway, it's a fun distraction. Shows how far medicine has come in many respects, but also how much has remained the same. A lot of the terms used exclusively in medicine today are unchanged from a century ago, particularly the anatomical terms. I've got a physics background, so I'm used to learning about discoveries from centuries ago, but medicine we often think about as a more modern creation. My fancy old-school medical dictionary is a nice reminder that all we know has been developed over a very long period of time, a knowledge base built by a very large number of people.

Monday 21 December 2015

Documentation

I requested a rotation away from my home school for my FM block, one that I'm really excited about. Unfortunately, I've just been informed that I have to submit a giant heaping pile of documentation about my immunization status. Now, I've had to submit all this stuff to my home school already. I've had to submit it to the hospital three times. I had to submit it to my undergrad school too, plus at least two volunteer groups. At some point along the line, can't it be assumed that either I'm immune to the things they want me to be immune to, or at least I'm so good at faking it that I'll fool them too?

They don't just want the documentation either - they want a physician or nurse to sign off on it. Exactly what a physician or nurse can do to look at my documentation that anyone with eyes can't, I have no idea, but it's required, so I have to do it.

Worst, I don't know where my N95 mask certification went. I think it got automatically submitted to my home school and I have to go through them to get it, but I may have just lost it, which means I'll have to repeat the testing since my previous was slightly over 2 years old. Nevermind that I've been tested at least 4 times, each time getting fitted with the 1870 mask. Nevermind that I've never had to use an N95 mask and am starting on a rotation where the likelihood of me needing one or even being in a facility with a variety of N95 masks on hand is slim-to-none. Nevermind that if I do need to wear one, since I don't shave every day - and am not required to - the small amount of stubble I'm likely to have would break the seal. Nope, if I can't find that piece of paper that confirms what another piece of paper from 2 years ago said, I'll have to go through the testing process all over again.

Just a great use of my time, the doctor or nurse's time I'll have to take up, and healthcare/medical education dollars in general.

Anyway, it'll get done. I had to get a lot of this stuff together anyway for electives in the fall, but it was a bit shocking to be rushed into it on my first day on vacation...

Saturday 19 December 2015

Vacation Time

During clerkship at my school, we get a grand total of 3 weeks off during the year and no, we don't get to set when they are. Today I start my first week of vacation! Unless you count the time I was sick and on the floor with stomach flu (and I don't) this is the first time in 4 months I'm even getting a full 72 hours away from the hospital.

And wow, did I need a break. I've worked far longer than 4 months straight before without much difficulty before, but there's a huge difference between working 40 hours a week with weekends off, (or being in school 25 hours a week with an extra 30 for studying/ECs set on your schedule), and working 60 hours a week, including nights and weekends regularly, with another 15 devoted to studying/ECs, all mostly out of your control to schedule. I'm tired. I've probably had 4 weeks in the last 4 months where I wasn't chronically tired, and only a few days where I felt truly rested.

I thought I'd take this opportunity to go through some of my fatigue-coping strategies. None of these are overly unique, most of them have an evidence base behind them, but I think they're worth highlighting.

#1) Make Time For Sleep

The average person should sleep 50-55 hours a week, ideally on a regular schedule. Some people can get away with less, maybe 45 or even 40 hours on the low end, but less than that generally means chronic sleep deprivation. I need sleep on the higher end of the spectrum - if I start dropping below 50 hours of sleep in week, I'm exhausted.

So I put the emphasis on sleep. If I'm tired, I try to go to bed an hour or half-an-hour early. I set my alarm as late as I can get away with. If I have a choice between getting an extra hour of studying and an extra hour of sleep, I choose sleep.

I know classmates who don't make this choice, and you can see the fatigue. Maybe they handle fatigue better than I do, most are a few years younger than me, but I can't imagine the difference is that great. Chronic fatigue makes us worse students and worse physicians-in-training, so I make time for sleep.

#2) Exercise!

The benefits of exercise as numerous and its effects on fatigue and alertness are well-established. It's tough to get enough exercise when you're lacking time and are already low-energy, but it's important to remember that exercise is an energy investment - you give up some energy now for more energy overall.

I walk to work. I walk from work. I walk the dog at least once a day, often twice, and I have a big, active dog. I take stairs in the hospital when I can. It all adds up to a good amount of activity.

Nevertheless, that's probably not enough. I should be getting more moderate- or high-intensity exercise on a regular basis. In contrast to my sleeping patterns, I know classmates who do a much better job of prioritizing exercise than I do. I should really be hitting the gym. This is on my to-do list of things to work on moving forward.

#3) Taking Little Breaks

There's no time in clerkship for long breaks, especially if you have obligations at home. Even an hour away from any responsibilities is hard to get on a regular basis. That's where small, 5 to 15 minute breaks can be a huge help. The key is to make it a true break - to get away from all stressors and to let your mind rest or work through whatever it needs to work through. Sometimes that's taking 15 minutes before bed to just process what happened during the day. Sometimes that's taking 5 minutes in the morning to relax and just have a clear head for the coming day.

Like most people, I use music to help take a quick break. Music, especially familiar music, is naturally calming (even if it's high-intensity music) and helps screen out other distractions without taxing your brain. I tend to draw on a small number of songs that I listen to ad nauseam. My go-to song is Matthew Good's Sort of a Protest Song:


Besides just being a good song with a relatively calming melody, I listen to it because its theme generally matches my mood when I need a quick break. Between the lyrics and what has to be my favourite title for any song, it expresses my sentiments all too well - that I'm tired from being "on" for too long, it sucks, I don't like it, I'd really like to stop, but I have to keep going and I know it.

Alright, not just that I have to keep going, but I want to keep going. As much as I complain about medical school, that I definitely don't want to do what I'm currently doing for the rest of my life, and that I'm incredibly frustrated by so many aspects of my medical training right now, I want to see this through to the end. I still value the end goal and would hate myself if I gave up.

So, I take 6 minutes to listen to Matt Good and have my little non-protest protest against my current situation. And then I put my jacket on and head out the door, just a little bit more rested.

Tuesday 15 December 2015

It's Alright to Hate Medical School

Stumbled across these two blog posts which present a wonderful contrast of opinions on views of medical school. I encourage anyone reading this post to read those two, but then to pay particular attention to the comments; they're just as revealing as the posts themselves. Some people love their time in medical school, approaching every aspect with unbridled enthusiasm. Some people hate their time in medical school, grudgingly dragging themselves through every aspect.

Of course most people fall somewhere into the middle with a lean towards one side or the other, but I there are more than a few people decidedly on one end or the other.

I'm definitely in the latter category. Ok, I don't hate medical school, certainly not 100% of the time, but I'm frustrated with my experiences in medical school far more often than I've been happy or even satisfied with them. The second post linked almost perfectly explains why I feel this way: I got into medicine to connect with people in a meaningful way and, ideally, to have lasting, positive impact on their health and/or lives in general. Yet, medical school more often than not pushes me in the opposite direction.

Meaningful contact with other people - even simple human interaction like normal people do each and every day - is secondary and often discouraged. Much of the health care system, including a good portion under the control of physicians, does not seem designed to provide adequate care, let alone excellent care. As the lowest person on the totem pole, you have no choice but to go along with what I consider substandard or fractured care. I can hate it all I want, but not only do I have to put up with this system, I have to advance and at times defend that system.

Let me be clear - the care is substandard, but the medicine is usually (though not always) fine. And that gets to the heart of the divide in viewpoints on medical school. For me, medicine is the means to an end. I want to help people, but don't particularly care how as long as it's effective. Good medical care can have an incredibly beneficial effect on a person's life, but getting the medicine right is only the first step in getting good care. It's necessary, but not sufficient.

Yet for some physicians or physicians-to-be, the medicine isn't means to an end, it's an end itself. For those who love the medicine, I imagine medical school is great, it's very much focused on acquiring and refining medical knowledge. For those of us who are very much patient-focused, learning about the medicine at the expense of forgetting about the patients is not a worthwhile trade-off, even if it is (hopefully) a temporary one.

This is not to suggest that people who love medical school are not going to care about their patients. It's a spectrum - some people who love the medicine are keenly devoted to the well-being of their patients, while others couldn't care less about their patients' ultimate well-being, with most falling somewhere in the middle. Likewise, those who are less-than-impressed by medical school are not guaranteed to be good with patient care - there are lots of reasons to dislike medical school and a desire for greater focus on patients is only one of them.

I will fully admit though that I get more than a little concerned about my ever-happy-with-medicine classmates, though I generally think they'll make good physicians, and the crux of that concern is that they're might not be seeing the faults or flaws in the current system. Calling medicine broken is a bit hyperbolic, but the further I get into it, the less hyperbole I see in that statement. There are some serious, deep issues in the medical professional that are going to take a long, concerted effort to change. I can't see those issues and not get upset that part of my training involves being forced to entrench those issues further, so to see people go through that process happily makes me worried that they'll be part of the next group of physicians fighting to keep the system broken...

If this whole post makes me sound like a pessimist, I want to stress that my frustration comes from a very deep-seated optimism. I dislike much of the current system of both medicine and medical education because it could be so much better and I believe we can make it better. I see so many colleagues with the intelligence and compassion to make productive changes; there's no shortage of ability. Yet, there may be a shortage of will. The more people with power who are happy with the status quo - and in medicine, people with power often means physicians - the more likely the status quo is going to stick around. In that sense, a few more dissatisfied medical students wouldn't be so bad...

Thursday 10 December 2015

Predicting Specialty Competitiveness

I like to think I have a pretty good handle on specialty competitiveness. I spend way too much time pouring over CaRMS stats and have used them to calculate a few of my own numbers on competitiveness each year. (Disclaimer - my preferred metric, 1st iteration match rate by preferred specialty to that discipline, has been produced by the CFMS as part of their fantastic annual Matchbook each year, so I'm not coming up with much that's original).

Anyway, while historical match rates in each specialty are interesting, what everyone cares about is predicting future match rates! "Is X specialty more competitive this year than in the past?"

Well, I'm going to put my knowledge to the test. Based on last year's match rate, historical trends, current job market, changes in lifestyle/income, and random rumors I've heard, here are my predictions for the competitiveness of the larger CaRMS first-entry specialties:

Anesthesiology
2015 Match Rate: 71%
Mediocre (but not terrible) job market with a good lifestyle and good income. Has been trending towards being more competitive. Hearing this is a uniquely competitive year.
Predicted 2016 Match Rate: 67%

Dermatology
2015 Match Rate: 51%
Good job market, good pay, great lifestyle. Been quite competitive recently, but no reason to think that'll change. No rumors to report.
Predicted 2016 Match Rate: 53%

Diagnostic Radiology
2015 Match Rate: 74%
Mediocre job market, declining lifestyle, great income (but declining fast in Ontario). Historically competitive but much less so in the past few years. 2015 might have been close to where Rads was 10 years ago, but it's a divergence from the recent trend. A regression to its typical low-80's rate would be expected and word is applications are down this year.
Predicted 2016 Match Rate: 82%

Emergency Medicine
2015 Match Rate: 56%
Great job market, good pay, lifestyle either horrible or great depending on your feelings about shift work. EM became more competitive recently, but even then, last year saw a fair-sized drop in the match rate. A small regression wouldn't be surprising, but interest is still high and somehow the field lost two spots in this year's match (?!).
Predicted 2016 Match Rate: 56%

Family Medicine
2015 Match Rate: 96%
Great job market, low pay, moderate (but flexible) lifestyle. Interest in FM has been steadily growing and I hear this year is no exception, but it's also a widely-accepted back-up specialty, so more interest doesn't necessarily translate into a lower match rate. People backing up might just lose out. It's also a huge field, so the match rate can't drop by much without a massive swell of interest.
Predicted 2016 Match Rate: 95%

General Surgery
2015 Match Rate: 85%
Pretty poor job market, rough lifestyle, good pay. Interest in surgery overall is declining a bit. Haven't heard too much about this year's match.
Predicted 2016 Match Rate: 84%

Internal Medicine
2015 Match Rate: 95%
Variable lifestyle, income, and job market, depending on subspecialty. Seems to be losing interest from students, but it's still the second-largest specialty. Nothing in the rumor mill to report.
Predicted 2016 Match Rate: 95%

Neurology
2015 Match Rate: 79%
I probably know the least about Neuro's practice situation so take this one with a grain of salt. Widely variable match rate recently, but 2015 was oddly competitive. Expecting a regression.
Predicted 2016 Match Rate: 85%

Obstetrics & Gynecology
2015 Match Rate: 73%
Mediocre job market, reasonable pay, but rough lifestyle in many respects. Competitiveness has grown recently. Does the trend continue, plateau, or regress? Hard to say. My money's on plateau.
Predicted 2016 Match Rate: 75%

Ophthalmology
2015 Match Rate: 74%
Poor job market, but awesome lifestyle and incredibly high pay. Competitiveness jumps year-to-year, but the match rate is usually lower than 2015's 74%.
Predicted 2016 Match Rate: 68%

Orthopedic Surgery
2015 Match Rate: 90%
Terrible job market (in Canada at least), but plenty of demand for procedures. Pay's decent, lifestyle's typical for surgical specialties. It's declining in competitiveness for good reason, but surgical specialties still garner substantial interest.
Predicted 2016 Match Rate: 87%

Otolaryngology
2015 Match Rate: 62%
Bad job market, good pay, decent lifestyle for a surgical specialty. Bit of a uniquely competitive year in 2015, but I'm hearing that level of interest is holding up.
Predicted 2016 Match Rate: 63%

Pediatrics
2015 Match Rate: 80%
Alright job market, alright pay, alright hours. Really stable match rates, even for a large field. People either love it or hate it, so the interest stays pretty constant.
Predicted 2016 Match Rate: 79%

Physical Medicine & Rehabilitation
2015 Match Rate: 76%
Good job market, alright pay, good hours. Quickly becoming a recognized lifestyle specialty and not without cause. More interest in recent years has translated into a big jump in competitiveness of the specialty last year. No firm whispers to report, but it sounds like this is a sustainable change, rather than a blip.
Predicted 2016 Match Rate: 78%

Plastic Surgery
2015 Match Rate: 53%
Alright job market, for surgery at least (OR time still a bit of a problem). Decent lifestyle for a surgical specialty as well. Good pay. Has been consistently competitive, match rates <60% for the last 5 years. Don't expect that to change.
Predicted 2016 Match Rate: 55%

Psychiatry
2015 Match Rate: 88%
Great job market, good lifestyle, but low pay. Interest in the field has grown, but that growth has limits - many students rule out Psych early and definitively.
Predicted 2016 Match Rate: 88%

Urology
2015 Match Rate: 81%
Poor job market, but good pay, and on the better side of things lifestyle-wise for a surgical specialty. Was less competitive in 2015 than typical, expect slight regression.
Predicted 2016 Match Rate: 77%

I should probably define what I'll consider to be an accurate prediction. Since more competitive specialties also tend to be more variable, I'll count a "success" as being +/- 2% if my prediction is over 90%, +/- 3% if my prediction is between 75% and 90%, and +/- 4% if my prediction is below 75%. In any case, it's written down, we'll see how my predictions turn out!

Wednesday 9 December 2015

Likes and Dislikes in Emergency Medicine

My school gives us a very quick rotation through our hospitals' Emergency Departments. It's been pretty fun! Here's what I've taken away from my brief time in the rotation:

1) Scope of practice: everything

Everything comes through the ED. Every body system, every age, every stage of life. Sure, there's the bread-and-butter conditions (I've seen a lot of chest pain this week), but the variety is really unique compared to other specialties. I've had more "firsts" in my medical training this past week alone than in the previous 3 months of clerkship and 2 years of pre-clerkship. I'd say this is the first rotation where I've come home excited on a regular basis and it's because I've gotten to do something different every day. I'm really enjoying the diversity of conditions in the ED.

2) Oh, shift work...

The best and the worst part of EM is the same - you're working shift work at all times of the day. It's a bit disorienting. This week I got off a shift at 11 pm, then started my next one at 9 am the following day. I've got a shift that ends at 4 am in a few days. That throws off your internal clock a bit...

On the plus side, shift work is limited to, well, shifts. If you're scheduled for 8 hours, you get off after about 8 hours, with maybe half an hour or so to wrap up patients. You get days off, even during the week, to do things that normal people do like run errands, get exercise, and watch copious amounts of TV. For attending, shift work also means things like taking vacation are fairly easy to do. EM docs don't have their own patients, so any shift can be covered by any qualified EM physician. That makes taking some time off easy, you just ask to not have any shifts during a given period of time!

3) Process Improvement

I've been very frustrated with how the medical system (and the medical education system) is organized, especially within individual departments. The processes in place don't seem set up to optimize outcomes for patients, providers, or students.  Worse, efforts to improve these systems are non-existent or face substantial resistance from those in positions of power (often physicians).

In that respect, the ED has been a breath of fresh air, at least at my institution. The system isn't perfect, but it's clear efforts have been made to improve experiences for patients and physicians alike. More importantly, there seems to be a lot of energy being devoted to making the system better. Emergency departments have, rightfully, been the focus of a fair bit of criticism in the past, so maybe this is just a natural outflow of the field's past weaknesses, but I can't say how happy I am to see the status quo in medicine under scrutiny.

4) Rush, rush, rush

Everything moves pretty quickly in the ED. As a student, I'm usually at least partially shielded from the true craziness, but students aren't fully immune to the department's brisk pace. Most times I've been on so far, it'd been me working with a staff physician and a resident. Today, the resident called in sick and I was running off my feet trying to get patients moved through (or at least not slow down those who were actually moving patients through). It was both exhilarating and exhausting.

5) Not my job

If there's one thing I really didn't like about being in the ED, it's that they have a very specific role in health care. Once a patient is stable and there are no acute interventions to do for whatever brought them in, that's it, they're either going to be admitted or sent home. In most cases, this works just fine. In a select few, however, I found it a bit frustrating to go through a whole work-up that basically gave us the diagnosis, which has an obvious longer-term treatment that's easy enough for us to start in the ED, but we held off in favour of having them follow-up with a clinic or their Family Physician. I get it, long-term stuff should be covered by a physician following them long-term, but it sucks to get 90% of the way to solving the patient's problem and stop short of finishing the job.

6) The Happiness Test

The ED is a high-stress environment, where in any given shift, several of your patients could be at risk of death if not managed properly. When we're on the job and running around, I've certainly seen the serious, no-nonsense side of Emerg physicians come out. Yet, the second we have a chance to sit down, the seriousness disappears instantly and the smiles come out. Every physician I've worked with so far seems pretty happy, usually joking around between reviewing patients. They've all been incredibly nice to me so far. Maybe it's just my institution, maybe the only people drawn to the field are those who can handle stress with a smile, but I have to consider EM docs positive on the Happiness Test.

Monday 7 December 2015

Roles of a Physician

One common story about the horrors of being a Clerk is the need to do what's called "scutwork", which is basically doing annoying tasks that anyone can do but which no one wants to do. Clerks get to do these tasks because they're at the bottom of the totem pole in medicine and they can't say "no".

So far though, I haven't had any real scutwork to do. My previous work in healthcare definitely involved some of this, both as a student and as a practitioner. I collected garbage, changed linens, transported patients, ran blood samples to the lab... whatever needed to be done. Not the most fun work, but it served a useful purpose and was clearly part of my job. Physicians largely don't have these kinds of responsibilities - there are ancillary staff who take on these tasks - and so Clerks don't have to do it either. There's been very minimal menial labour so far (unless you count writing notes which, while monotonous at times, is usually very necessary patient care).

In some ways though, I wish there was some scutwork. Changing linens was annoying at times, but it was easy and a very tangible way to contribute. For Clerks, who really aren't good for much productive on the medical side of things yet, there are worse things than having an easy, useful task to complete that others would rather not do.

More importantly, I think it's worth remembering that an MD says what we can do, not what we can't. Physicians are very privileged to be able to do almost any task in healthcare, including some very cool, very useful activities that most other people are legally not allowed to perform. But just because there are virtually no tasks above the scope of practice for a physician, that doesn't mean there are skills below the scope of practice for a physician. I can still bring a patient their meal. I can still bring them a blanket. I can still change the linen basket in their room.

I won't do these activities on a regular basis - there are people paid specifically to do these tasks and they know how to do them more efficiently than I do - but like most people, I got into medicine to help people. If that means performing a careful examination, doing appropriate tests, formulating an accurate diagnosis and determining appropriate treatment, great. If that means grabbing a warm blanket from the warming cabinet, also great. In all honesty, sometimes I wish I got to grab more blankets for patients - it really can go a long way to make them feel better when they otherwise might not feel all that great.

Wednesday 2 December 2015

Do a Full History and Physical

Here's a tip to current instructors of medical students, as well as to hopefully myself in the future: never tell a student to do a "full history and physical" without defining exactly what that means in the given context. I've gotten that piece of advice from a huge number of instructors and residents, some of them otherwise very good instructors.

The idea, presumably, is that I should be thorough at my stage in training. Lacking enough experience to know exactly what the right questions are, it's better to ask too many questions and have some be meaningless than to ask too few and miss important details. Same goes for physical exam - too much is preferable to too little. That I get.

But a true "full history" would be a waste of time for everyone involved, not least for the patient. I can ask every question I can think of, even if it's unlikely to have any relevance. I can do every physical exam test I know of, but most would be useless if not nonsensical. What most people mean when they say "do a full history and physical" is "cover the standard questions and examinations for this specialty". Yet, what the standard is changes from specialty to specialty, sometimes dramatically. In kids I learned that I should pretty much always look in their ears. In adults? Not so much. The only way to know that for an otherwise naive student is to be told.

That's where "do a full history and physical" really fails - it's specific to the speaker, who lives wholly within the context of one specialty, but is vague to the listener, who jumps between specialties with regularity.

So in the future, when talking to an undifferentiated learner in medicine, please, just say "always ask this, this and this, then do this, this and this on exam". It'll be far more helpful than to say "do a full history and physical".

Tuesday 1 December 2015

Med School Curriculums Across Ontario

One interesting aspect of clerkship is you get a lot more exposure to students who are going or went to different medical schools across the country. We have elective students rotating through working with us, and many of our residents trained at other schools originally. I go to an Ontario school, so most people I encounter are from Ontario schools as well, but there's still a fair bit of variety. One topic that's come up a lot in conversation - and I swear I'm not initiating these because I'm a medical education geek - is how our schedules in clerkship and medical school in general differ. It's interesting to see what each school considers important enough to specifically highlight in clerkship, or what parts of school come where during the 3 or 4 years. Talking with the McMaster students has been the most interesting, because they have a 3 year program that's all over the place.

In broad strokes, most schools still do the traditional North American model for medical school:

Years 1 & 2: Pre-clerkship, consisting of lectures, small groups, plus some training taking a basic history and physical.
Year 3: Core clerkship, consisting of a standard set of rotations (IM/Gen Surg/FM/Psych/Peds/OBGYN with ER and/or Anesth often thrown in there somewhere)
Year 4: Electives, where you do whatever you want wherever you want to tailor your education (but mostly to impress whoever you want to impress for CaRMS).

Pre-clerkship years typically come with a few months of summer while Year 4 ends early to allow time off before residencies which start in July.

Talking to current or former students from other schools, I've gleaned a few take-aways on how medical school could or should be set up:

1) Rotation length isn't that important in clerkship. My school does 6 week blocks for its core rotations, often broken down into sub-rotations of 2 weeks each. IM and Surgery are combined into 12 week blocks, but get some more selective time. Other schools seem to do 4 week blocks and include selective-only blocks. Doesn't seem to make much difference. I generally like the way my school has broadly organized its clerkship, but see nothing wrong with the other systems.

2) Core rotations should come before electives. McMaster doesn't just do a 3 year program, it does a very jumbled 3-year program. Electives come before core rotations in a lot of cases and students don't seem to like that at all.

3) Electives are for CaRMS - and the more pre-CaRMS electives the better. Regardless of what schools or programs think electives are for, students are very clear: they're for finding out what the right residency is and matching to it.

4) 3-year programs are completely viable. McMaster unfortunately has a reputation that its clerks are less knowledgeable than clerks from 4-year schools. I've seen signs of this, but nothing consistent or egregious. More importantly, the school's match rate is good, former Mac students do fine as R1s and also do fine once they get out into practice. Maybe there's a small deficit in medical school, but who cares? School's meant to be a learning experience and the end-outcomes are fine.

With these in mind, I'd like to propose the following broad curriculum schedule for medical schools:

Year 1 (Sept-May): Preclerkship, consisting of lectures & small groups, with a heavy emphasis on practical skills like taking a basic history and physical. One month of summer in June for travel and stuff.
Year 2 (July-June): Clerkship, consisting of the standard set of core rotations. Some weeks of didactic training would be interspersed to make up for a shortened pre-clerkship.
Year 3 (July- May): Electives, consisting of in-hospital electives until end of Dec with in-class/simulation electives and consolidation from Jan-May.

The idea here is to sacrifice a good chunk of pre-clerkship and some in-hospital training during clerkship itself in favour of increased elective time (particularly pre-CaRMS elective time) and one less year of training. First year would be an utter crash course in medicine, focusing on the sheer basics. Some things undoubtedly get lost by cutting out what amounts to about 9 months of in-class instruction, but short training times also force some efficiency on curriculum designers and mean there's not much time for knowledge to be lost before clerkship. Pre-clerkship is pretty inefficient, with plenty of low-yield content and poor approaches to long-term learning. Off the top of my head I can think of several months worth of material that could be tossed from my school's pre-clerkship curriculum without much consequence - there's plenty of fat to cut before getting to the meat of pre-clerkship.

The chance to make up that depth comes in increased clerkship classroom-based instruction. I'm pretty outspoken about how lectures are rather useless, but there is a role for hands-off learning in applied fields like medicine. By linking teaching more closely with clinical experiences, the chances of long-term retention are much higher.

The increased elective time is pretty self-explanatory and mostly just represents a re-scheduling. At my school, we get quite a few selectives through our third year, which are often quite enjoyable rotations, but are hardly necessary. By switching these out for true electives students can get a bit more control over their future and have more time to feel out their career goals, especially before having to apply for residencies.

This system would not be without its own downsides, but I think on the balance far more is gained than lost. As always, I'd love to hear opinions on such a system, positive or negative - it's something that's been rattling around in my head for a while, and it's been good to type it out!

Thursday 26 November 2015

One Year 'Til CaRMS Applications

I've missed the boat by a few weeks, but the 4th years were all busy in the hospital getting their CaRMS applications in. Very excited for them, especially the many excellent students I've worked with in clerkship. I'm particularly thankful to the elective student who was with me on my first week, they were an enormous help in getting adjusted to all things clerkship - while I hope everyone gets a residency they'll enjoy, I have to send extra good vibes to this person.

Ok, enough about other people! Me time! Ok not really, I'm really excited for the 4th years I know going through CaRMS, just couldn't think of a better segue.

I've been giving a lot of thought to my career in the short- and long-term given what I've learned from my time in clerkship. As I'm basically a single year from my CaRMS applications and specialty choice is a fairly important part determining my career direction, I've been narrowing down my options pretty quickly.

I'm finishing up my Pediatrics rotation now. I wanted it early because it was essentially at the top of my specialty list when clerkship started. It has a lot of practice options, there's a fairly holistic approach, people who work in Peds are generally good-spirited, and I really like working with kids. I had a good rotation, minus the traditional Peds rotation illnesses. My residents have been great, the kids were awesome to work with, the medicine was interesting. Yet, Peds is no longer my #1 choice.

As much as I liked Peds, I didn't love it either, and it comes with some downsides. Still not big on inpatient medicine, which is a huge part of Peds residency (consultants have some choice on this). The hours, while not nearly as bad as OBGYN, are still fairly long, with frequent overnight calls (that also gets better once becoming a consultant). The job market is pretty tight for Peds specialists, and I'd have to move a lot to pursue subspecialty training, likely to places I don't particularly want to go. I liked Peds ER, and that was definitely something I was thinking about beforehand, but I don't know for how long I'd be able to handle true shift work. It's not terrible now, but I don't think I'd be comfortable with the chaotic schedule in 10-15 years. If I could get regular shifts week-to-week that'd be one thing, but it's just a very messy arrangement. That pretty much leaves Community Pediatrics, which was also something pretty high on my list. It hits many of my preferences and has a decent job market.

The other specialty I'm considering is Family Medicine. While it's not the only difference, the main contrast between FM and Community Peds is simply patient population. One deals with all ages, the other is kids only. I like working with kids. I also like working with adults, including the elderly. Do I like working with kids more? Maybe. Not totally sure. But I know the difference isn't substantial, if one exists at all. It's pretty much a wash to me in terms of final working conditions.

So it comes back to residency. 2 years vs 4 years. Primarily outpatient vs primarily inpatient. Non-competitive vs competitive entry. Variety of locations vs only major centres.

A common refrain I hear from staff and residents is that you shouldn't avoid a specialty you like because the residency sucks. I appreciate the logic - no point being miserable for decades of your life in a less-than-ideal specialty to save yourself a bit of pain in the early years, and some sacrifices early on can lead to long-term gain.

But that only makes sense if there is a big difference in long-term payoff between specialties under consideration. For me, there doesn't seem to be one. Just as importantly, the next few years really matter to me - it's when I'd like to get married, buy a house, have kids. Trying to accomplish these life goals while in a time-intensive residency - or delaying them in order to finish residency - isn't a trade-off that seems worth it given the minimal differences in factors that matter to me between FM and Community Peds.

This is my long-winded way of saying I'm gunning for FM now. I don't have too many other question marks about other specialties - I either know I don't like them, or there's no compelling reason to prefer them over FM or Peds. Maybe I'll discover I hate FM when I rotate on it, but I've had decent exposure to the field so far and have generally enjoyed it, so I'm hopeful I won't be unpleasantly surprised. I'm a year away from having to make the final choice, but for the first time, it feels like I'm finally settling on a concrete option. That in itself is a huge stress reliever during the otherwise stressful time that is clerkship.

How Predictive Are Med School Exams?

It's been evaluation week on my clerkship block (don't worry, passed everything), and it brought up an interesting discussion - just how predictive are tests in evaluating students' likelihood to do well in practice? My block evaluations were quite fair, I certainly can't complain about them, but they did contain some odd elements that probably aren't too meaningful to future practice.

When we talk about testing in medicine, the sensitivity and specificity come up a lot. In medical education, those concepts could easily be applied - that is, how likely is it that a good future practitioner passes a given evaluation, and how likely is it that a bad future practitioner fails it? Outside of Quebec, Canadian medical schools use a pass/fail system with pass levels that are not particularly high. It's not too hard to pass the formal evaluations. And, in the event of an "off" day that results in a single failed evaluation, a repeat is typically granted without punishment provided it's not a regular occurrence (and you pass the repeat of course).

These tests are generally designed to identify unacceptably poor students and while individual tests might mistakenly call a good student inadequate, on the whole they're probably letting through students with trouble more so than they're failing otherwise good students. They have a high specificity, in other words - a true fail likely means the student has true issues to be addressed. They're probably not that sensitive though, so a pass doesn't mean much.

Predictive values of major tests have been studied in the past, but I've yet to see an analysis along the sensitivity/specificity lines. Mostly previous literature on the subject has demonstrated correlations, with the strongest correlations usually occurring between similar assessment tools (eg GPA correlates reasonably well with pre-clerkship grades, while MCAT correlates with the USMLE Step 1, but the correlation is weaker for other medical school metrics).

Anyway, not super useful right now, just another time to note that while we're busy developing evidence-based medicine, we're pretty far behind when it comes to evidenced-based medical education.

Sunday 22 November 2015

Continuity of Education

Continuity of care is an oft-discussed topic in medicine. Oversimplifying a bit, it means having the same provider or set of providers care for a single patient over time. The major upside is that the providers are fully aware of the patient's medical history and only need updates in between encounters rather than starting from scratch. Same goes for the relationship between patient and provider - rather than having to build it at each encounter, the relationship can be built and sustained over time. Implemented effectively, continuity of care should improve efficiency in medicine and quality of care.

The other facet of continuity of care is a seamless or near-seamless transition between various healthcare providers, when a transition is necessary. That is, providers should communicate well when referring patients between themselves and have a coherent plan for all aspects their care.

When it comes to education, continuity is equally important. We all have our challenges when learning a new task or skill, and medicine is no different. Overcoming those struggles is often a long-term prospect, requiring multiple different strategies before settling on an appropriate course of action. Having a single instructor or close-knit group of instructors can be enormously beneficial, as feedback can be given on new strategies with the results of previous efforts in mind. With a single instructor, a student's unique challenges, along with their strengths, don't have to be re-established at each encounter and can be incorporated into a plan for improvement moving forward. On an even more basic level, lessons can be tailored with full knowledge of gaps in previous lessons in mind.

Yet when it comes to medical education, particularly at the medical school level, continuity in education is virtually non-existent. In my third year of study, I have never been evaluated by a single person more than twice, other than maybe having the same person mark my exams (ie never an in-person evaluation, I'd just be a name to them, not a face). Where twice did happen, it was always in a single semester for a single class, typically only a few weeks or months apart. Never was there communication from one instructor to another on my strengths or weaknesses. It's a very fractured system.

If a student is generally doing well, this isn't too much of a concern - they'll pick up the little suggestions from each instructor and incorporate them as they move forward in their training. It's still not ideal, as more subtle problems often go unaddressed entirely and small issues can persist even if addressed, but the consequences aren't dire in these situations. For individuals who do struggle, lack of continuity can be a huge problem. Lack of progress isn't readily identifiable, since instructors only see a snapshot. Where progress is made, it generally goes unacknowledged - struggling students are either only recognized as being adequate (with little fanfare for the student's successful efforts), or inadequate (ignoring significant improvements the student may have made between evaluations).

In the worst situation, struggling students are passed without much feedback even if there are significant concerns. Most instructors are keen to help students improve, but they're also heavily incentivized to pass students along. When an instructor will likely never deal with a student again, they have no real reason to address problems. I see this way too often - when I ask for areas to improve upon, and I do at every evaluation, the most common answer is something along the lines of "not really, just keep doing what you're doing and reading". I'm a good student (I think), so I'm not expecting a litany of problems, but I do know that I'm far from perfect and that there are things I should be working on. I can easily see a struggling colleague getting the same treatment. When a student's problems do become too significant to ignore, it may be late in the game, in clerkship or later, and the realization of inadequacy can come without warning for the student. At this stage, opportunities for effective remediation are minimal, and high costs have already been borne by the student, who is now years into their training and tens of thousands of dollars in debt.

Medical education research has started to come to the conclusion that education isn't just the mechanical transmission of information from one person to another in the way a computer transmits data. Investment on the part of both the student and the instructor matters. As medical education evolves, we'll need to figure out a way to link students up with their evaluators over a longer period of time. A series of disconnected learning opportunities are simply not good enough to reliably ensure excellence in education, even if each individual educational event is of high quality. We need a higher focus on continuity in medical education.

Friday 20 November 2015

Syrian Refugees

Only tangentially related to medicine, but it's been in the news almost constantly and is a really good case study in the intricacies of actually helping others - and how intuition can undermine those efforts.

First and foremost, there's been an attitude floating around that Syrian refugees should be going to countries more similar to their ethnic, cultural, or socioeconomic backgrounds, particularly countries nearby. The thing is, they have. In massive numbers. The number of internally displaced Syrians is enormous, hundreds of thousands have moved within the country to avoid the conflict. Millions have relocated to nearby Turkey, Lebanon, and Jordan. A mere fraction of the approximately 4 million Syrian refugees have gone further than the Middle East, most to Europe. If Canada took even the 25,000 proposed refugees, it would represent a drop in the bucket compared to the number of total refugees. The proposals on the table don't represent Canada being enormously generous - we're mostly bickering about us barely doing our part to help refugees.

Perhaps more importantly, some of the need to relocate refugees to countries like Canada is a direct result of an unwillingness to be charitable beforehand. While hardly the only factor, a major contributor to Syrian refugees attempting to settle further away than Syria's neighbours is the horrible conditions in these refugee camps. Turkey, Lebanon and Jordan are not horribly poor countries, but they're not excessively rich either, and they have taken on a massive number of refugees. Lebanon, for example, has taken on at least 1.1 million Syrian refugees, in addition to another 500 thousand or so refugees from other countries (mostly Palestine), yet the number of actual Lebanese citizens is only about 4.1 million - over a quarter of the people in Lebanon are refugees! They needed (and still need) financial support to care for all these refugees properly and despite a mountain of promises from Western nations, that didn't come. If more Syrian refugees could have stayed in a reasonable state in the Middle East, we'd have less needing relocation. Western nations, insufficiently sensitive to the needs of these refugees, now find themselves in a penny-wise, pound-foolish state. Rather than cough of some money to support refugees close to their homes, they are faced with the prospect of higher costs to absorb refugees directly. Perhaps most ironically, the most vocal opponents of foreign aid are often the most vocal opponents of accepting new refugees, even though proper funding of foreign aid may have minimized the current refugee crisis, and potentially side-stepped the issue of accepting refugees in the first place. The Syrian refugee crisis is an odd case of self-defeating xenophobia.

Now, the past is the past - we can't now change the fact that there are thousands of Syrians who need a new home. Bringing some to Canada will undoubtedly help them, but could it hurt us? The Paris attacks have exposed lingering fears about the possibility of a terrorist attack in Canada, and that fear is being directed towards Syrian refugees. Unfortunately this is guilt by association. Heck, not even guilt by association, it's guilt by proxy. There's not much evidence that these refugees - or refugees in general - are at higher risk of committing violent acts, including terrorism. The Paris attackers were all EU nationals as far as we know, not refugees. Even if one or two come up as refugees, the majority will still be EU citizens. It's worth remembering that these people are running away from the very extremists Western citizens fear. While we're worried about being potential victims of extremism, these are actual victims of extremism. They deserve help.

Concerns about adequate screening have also come up frequently in the conversations I've heard/read. It's absolutely fair to want to take appropriate precautions against a Trojan Horse of some sort within the refugee population. However, no screening process will be 100% effective. Not only can good screens miss pertinent information or be fooled, but those who commit future attacks may have no plans to do so now. I have the dubious distinction of having amicably spent time with a terrorist, who eventually went on to be a suicide bomber. Of course we were in public school at the time, he wouldn't become radicalized for years after I knew him. But I never would have guessed he'd end up a terrorist and if any adults did at the time, there certainly wasn't any indication. Point is that background checks are only so effective and you can't just pick out a terrorist, even with extended close contact.

And that brings me to my last point. We often think of terrorists as fundamentally bad people. Certainly, anyone who commits atrocities like what happened in Paris has perpetrated a horrible crime and deserves punishment in accordance with the laws of a just society. Yet, terrorists aren't born evil, nor are they influenced solely by other evil people. They're affected by their circumstances, just as all of us are, and even good intentions can push people towards a bad path. My friend from public school - and at the time, I did consider him a friend - wasn't particularly malicious or cruel at the time. He could be a bit mean at times, but no more than any preteen. He did carry a lot of frustration though. Looking back, I can remember his fear, his anxiety, his anger. By the sounds of it, someone found an outlet for those emotions, and unfortunately it wasn't a positive one, which led him down the path towards terrorism. He had a lot of positive influences in his life too though. For my part, I hope I was one of those positive influences. But it wasn't enough, he got lost in the shuffle of life, and wound dead, far away from home, with his most notable impact on the world being cold-blooded murder.

Terrorists, as much as we hate to admit it, are just people, like you and me. Sometimes lost, sometimes confused, sometimes angry, misled, deceived, scared, or disturbed people, but still people.

And it is in this light we need to view Syrian refugees. They could become terrorists. Or they could become contributing member of society, including physicians - the number of immigrants to Canada who practice medicine is remarkably high. How we treat them will impact their future. Right now Western countries are sending a message that are not wanted, not deserving of help. To me, that can only build the fear, the frustration, the anger that I saw in my friend. By treating refugees with suspicion and distrust, we could easily create a self-fulfilling prophecy.

Yet we can also create the opposite self-fulfilling prophecy. If we accept these refugees with open arms, with compassion, we might find they're just as eager to help us as I hope we are to help them. We can keep trying to catch terrorists, foil terrorists, kill terrorists. Or we can try to stop terrorists from existing in the first place.

Tuesday 17 November 2015

Likes and Dislikes in Pediatrics

My second rotation of clerkship has been Peds. I'm getting closer to the end of it, so I thought I'd continue with what I started with my OBGYN and mention a few things I've learned on the rotation. Peds I wanted to have early in my clerkship because it was fairly high on my list of potential specialties to pursue for residency, but I hadn't had much clinical exposure in the field. It's been a good rotation to clarify my clinical interests.

Here are my take-aways thus far from Peds:

1) Kids are awesome

I like working with kids, of all ages and states of health. They're interesting to talk to, fun to examine (tickling as a distraction technique just doesn't work as well in adults), and you never quite know what you're going to get meeting a new pediatric patient. The social aspect is trickier, and parents can hinder care as much as help it, but most are good and I enjoy working with even the most troublesome parents. I know a lot of physicians view parents as an annoyance, I tend to see them as just another patient in need of care. A lot of pediatrics is about caring for the family as a whole, not just the sick child, and I really like that type of comprehensive family care (though in practice, it often falls short of where it ideally should be).

2) Not a big fan of inpatient medicine

I'm increasingly realizing that I don't like working in a hospital, especially on an inpatient floor. A lot of time is spent working around the patient rather than working with them, typically involving talking to other doctors. The patient or their family may or may not be fully in the loop. Interactions with each individual patient are infrequent, a few times a day at most, oftentimes much less. I find this problematic, especially considering the disruptive nature of hospitalizations to a person's life. Too often patients do not grasp why they're there, what they're doing that day, or even who everyone is caring for them. The medical aspects of inpatient care are quite interesting and it's a good learning opportunity. However, that tends to lead to good treatments, but overall care that is often rather poor or fragmented.

Inpatient medicine is also quite detail-oriented, but the importance of those details is not always clear. As I said, a lot of time is spent with doctors talking to other doctors, usually about these details. Yet, there are rarely consistent opinions in these discussions - talk to 5 different physicians you'll get 5 different viewpoints. To me, that means either inpatient medicine frequently gets things wrong depending on which physician's opinion wins out, or it doesn't matter which opinion you take and the details probably don't matter much. I lean towards the latter and I don't get particularly excited about spending most of my time quibbling about minutiae.

I enjoy big-picture problems and patient contact. Inpatient medicine doesn't seem have enough of either for my liking.

3) Infectious diseases everywhere

I got sick this rotation. A lot. With not-so-fun illnesses. Had to take only a small amount of time off, but it ate up what few breaks I got. The residents seem to have built up more of an immunity to the common bugs, but for a first-timer working with truly sick kids, I got hit pretty hard. It's really hard to work - especially on overnight call shifts - when you're not anywhere close to 100% health-wise. I said before that long hours aren't a good fit for me and I'd rather go for specialties that have fewer hours or allow for part-time work. Having the opportunity to take time off when sick would also be a huge plus.

4) The happiness test

Taking to heart the advice "Go where the happy people are", I'm keeping a close eye on how happy the people on each rotation seem to be. Pediatricians are definitely happy people. Some are a bit more reserved, some are definitely tired (residents far more than staff) and I have met the odd unpleasant physician on this rotation, but the average pediatrician is actively smiling.

Every specialty will have some very satisfied practitioners, as well as some downright miserable ones, but where the typical physician in that specialty falls is telling me a lot about the fields of work. In OBGYN, the typical resident or staff appeared exhausted but mostly contented. In Pediatrics, the typical resident or staff appears almost joyous, with maybe a hint of fatigue. Both are largely positive states of being, but the difference is evident.

Overall, Peds is still pretty high on my list of specialties to match to, but it's slipped a bit. I had thought about doing Community Peds or Peds Emerg and those both still seem like attractive options, but it would take 3+ years of largely inpatient pediatrics to get there. I'm not sure that's a worthwhile trade-off when Family Medicine is on the table, with its similar compensation to Peds, a much better job market, shorter residencies with a focus on outpatient medicine, and much more flexibility in terms of location or practice arrangement. I like working with kids, but I also find I like working with adults. The main reason to go into Peds would be to cut out the older people from my practice, so if I don't want to do that (or I'm indifferent to it), what's the point? Won't take long to be sure where I stand though - my Internal Medicine rotation is coming up next!

Saturday 14 November 2015

Priorities

I've worked with kids a lot, particularly before medical school. One kid, I'll never forget, had parents who were very interested in where he went to school, fighting rather hard to get him enrolled and transported to a particular school that they believed would give him the best education. They were adamant and dedicated to this goal.

And they were under investigation by child protective services, with the very real possibility of having their children taken away. Wait, what? Despite these parents' strong desire to have their child at what they believed to be a good school, these parents were neglectful, failing to provide adequate nutrition, as well as poor social, emotional, and structural support for their children. The kid I worked with spent so much time looking after their siblings, they never got a chance to be a kid. These parents weren't opposed to feeding their children, or providing the other necessities of life, but their priorities were completely out of whack. They'd fight for their children to go to a desirable school, which is an admirable thing for parents to do, but it's far less important than putting food on the table. The parents weren't overtly abusive, and had some good intentions, but they were nevertheless neglectful, and that had a huge negative impact on their children.

I bring up this story because I've been struggling a lot with priorities. Clerkship has made it absolutely clear that there are some deep problems in the way we treat patients, and in the way we educate physicians. Yet I've rarely seen too many clear instances of wrong-doing. I've heard stories of physicians who were dismissive or disdainful of patients. Others, who were verbally or physically abusive of students or residents. I've seen or experienced only minor instances of these abuses. Most physicians want the best for their patients and want students to have a good experience, as do most of the other staff responsible for patient care and student education.

However, I've still felt as though the healthcare system has been frequently failing to care for patients, and the education system has frequently failed to properly support students. Given the positive intentions and actions of the majority of the individual actors involved in these systems, I chock these failings up to neglect. And, just as the parents in my story were neglectful because their priorities were in the wrong places, so too does the healthcare system engage in routine neglect of patients due to misplaced priorities. Likewise, the education system frequently neglects the needs of students due to its priorities.

Let me give an example for each. In many departments in the hospital, the main interaction physician teams have with their patients is during morning rounds. Rounds are often fast - 15 minutes per patient - and may not include the whole team. The team itself can change frequently. It's not uncommon for a single patient to see multiple different physicians, residents, or students in the course of their care. Afterwards, the team of physicians may never see the patient again that day, hearing of new concerns or changes in their status only through nurses' reports. Yet, this team will be the ones making decisions on the patient's care, going beyond those 15 minutes of interaction per day only as necessary. Each provider is often courteous and caring during those 15 minutes, but for a sick patient, 15 minutes a day interacting with the people who are most responsible for their care isn't really enough to feel cared for or heard. This is particularly true when these physicians/residents/students are in a rush to finish, as they often are - other patients, mandatory teaching, meetings, and supplementary tasks all take priority to spending extra time with each patient. As much as physicians and trainees want to be present and provide full care for their patients, it is so low on the priority list that it is often neglected.

Same goes for medical education with respect to students. Physician educators care about the well-being of their students. However, when put up against training and testing, it falls in priority. This is how we get incredibly long work weeks for students (and burned out, exhausted students). While medical educators would rather have rested learners, when put up against getting extra hours of hospital time, it simply isn't a priority.

In each case, it's not as though the current priorities are inappropriate goals. In an ideal world, physicians would care for large numbers of patients, while participating in continuing education, meetings, etc. Students having a wealth of experience an admirable goal. Yet, is physician efficiency more important than those physicians spending sufficient time with each patient? Is another 10 hours a week in the hospital more important than learners having time to explore their own interests, spend time with the world outside of medicine, or simply to sleep? I would argue no.

Changing priorities comes with trade-offs, of that I am fully aware. Physicians spending more time with patients may mean more physicians overall and less pay for each. Less time per week in hospital for students may mean a reduction in knowledge at graduation (though studies on that subject are lacking/equivocal). Yet, if we want physicians to put the priority on the care of their patients, or schools on the overall well-being and success of their students, it's going to take embracing or adapting to these trade-offs. The mission statements of hospitals and medical schools often feature these priorities prominently - it's time for them to walk the walk, rather than simply talk the talk.

Monday 9 November 2015

Sick

Caught a stomach bug a few days ago. Not fun at all. Watery stuff coming out of everywhere. Fortunately it doesn't last long and I'm already on the mend.

First time I've had a true stomach flu though, so it's been an interesting learning experience. Had almost a textbook progression of the disease, which has made it almost comically easy to remember the timeline of a stomach virus infection - I just have to remember when my symptoms started up and when they left, which isn't that hard when many of those symptoms are physically horrifying. Not that I'm advocating med students all go out and get every infectious disease they can, but it's a good reminder that nothing teaches like first-hand experience!

Passion in Medical Education

Had a "bonus" teaching session the other day. Well, technically it was mandatory, but it wasn't part of the official curriculum and I don't think there were any consequences for missing it, so exactly how mandatory it was is questionable.

Anyway, it was pretty clear this was an initiative started by the instructor, not the school, to cover a clear hole in our official training. It was a fairly simple lesson, but very well taught and extremely high-yield. I got to put the lesson into practice mere hours later, to great effect.

I've noticed a lot of my best learning opportunities come outside the standard curriculum. Sometimes these are initiated in conjunction with the school, sometimes not, but they're always driven primarily by the instructors themselves. Looking back, most of my more enduring learning has come through these extra-curricular sources. There are some facts that just float around in your head and some that are practically burned in there and for me, pretty much all of the latter come from these informal sessions.

The classic approach to education is to set requirements for lectures and other educational activities, then to test to ensure the information has been passed on (as well as to promote self-study on the part of learners). This works reasonably well to ensure a minimal set of knowledge is acquired, but it's rather inefficient and not all that effective. The main problem is the classic approach relies almost solely on extrinsic motivation of students - using either rewards or punishments for doing well or doing poorly along whatever evaluation metric is employed. That encourages a lot of short-term learning, cramming, or strict adherence to what is being taught. In an expansive, evolving, and applied field like medicine, that's a recipe for inefficiency. Important information may not be emphasized sufficiently in the curriculum, may not be well-tailored to a student's eventual practice, and even if a student does well on a test or other exam, that knowledge may not be well retained in the future.

Extrinsic motivation is also at play when it comes to educators. I can't say how many times I've had a lecturer say "I've been asked to talk about this subject, so here goes..." Sometimes that works out and quality instruction is given. Sometimes the instructor knows their topic well, but isn't a great teacher, or doesn't understand the broader context of our education, and their lesson is rather low-yield. Sometimes the instructor is fine as a teacher, but they aren't an expert on their subject and are just doing the best they can. Schools use the carrot and the stick on their faculty members just as much as they do on students, with much the same drawbacks.

When an instructor goes out of their way to host a session, they are always an expert on the subject, they're generally good teachers, and the information they give is generally quite applicable in practice. Likewise, when a student goes out of their way to attend a session, they are almost always interested, attentive, and receptive. It only makes sense that I would have my best learning experiences in these situations - both I and the instructor were invested in me acquiring that knowledge. These activities draw on intrinsic motivation to learn, which is rather strong in most people, but I would argue is exceptionally strong in medical students and physicians who generally spend their whole lives in search of new knowledge.

The challenge with medical education - with all education - is how to rely more heavily on intrinsic motivation to learn while maintaining standards. After all, the reason extrinsic motivation is necessary at all is that all of us have some important aspects of medicine we're not horribly interested in, yet have to learn anyway. I think a major part of medical education would be to bring some more choice into play for both students and instructors, using the more heavy-handed approaches like mandatory sessions or high-impact testing only for the sheer basics. For the vast majority of medicine though, a bit more choice and flexibility - for students and instructors - could be a very positive thing. Sure, there'll be cracks in their learning without a centralized curriculum, but frankly, centralized curriculums have plenty of cracks anyway. An intrinsically motivated student, with enough time and energy, will have no problem filling those cracks in - an extrinsically motivated student has no such incentive.

Saturday 31 October 2015

Trainee Overload

Right around the turn of the millennium, provincial governments across Canada realized that we had been training too few doctors. Way too few. So they opened up a ton of new medical school spots, including a new medical school itself (NOSM), to fill the gap. Residency spots also expanded, with extra ones specifically for international medical graduates. The whole result was a rather massive and (by medical training standards) rapid increase in the number of trainees in medicine. In Ontario alone, 380 medical student spots were added between 2000 and 2010, up to 950 from a mere 570.

The overall merits of such a rapid expansion are complex and worth saving for a separate discussion, but for now I'd like to focus on one clear downside - trainee overload.

Despite all perceptions to the contrary, medicine isn't that tough. Each individual piece of knowledge or skill doesn't require super-human ability to accomplish. The challenge comes more from the volume of skills and knowledge required and the complexity of putting it all together in unanticipated or uncommon situations.

Acquiring this large volume of knowledge and skills requires an equally large volume of experiences. This is the major rationale behind long and intense training times. However, these factors are being undone by a greater increase in trainee volume. In medicine, patients are a resource, arguably the most important resource. If you're the only learner on a busy service, it's easy to maximize your experiences - you get first dibs on any interesting patients or on any procedures. You can perform to the maximum of your skill set and learn any appropriate new skills whenever an opportunity arises.

When there are more learners at your same level, you have to share. That means fewer procedures, fewer patients, fewer experiences. If the service you're on is particularly busy and there's more than enough to go around, that may not be as big a problem, but even then learning opportunities are not often maximized.

More consequentially, when there are more learners above your level, you get second billing. Rather than perform to the maximum of your skill set, you perform to the maximum of whatever's left over after your seniors have their experiences covered. That's a necessary set-up in these situations - we want senior trainees to be closer to competence than juniors, especially with respect to medical students who aren't necessarily set on a career course. Still, it does slow everything down, delaying trainee development and reducing volume or quality of important experiences. Something previously done by a senior resident is now done by a fellow; something previously done by a junior resident is now done by a senior resident; something previously done by a medical student is now done by a junior resident. Everyone can get set back a peg.

We haven't even hit the worst of it. Current PGY-5s and fellows came from classes that were, in total, 150 students smaller than today's class sizes in Ontario alone. As the PGY-1s and PGY-2s that came from larger classes move up, the competition for learning opportunities will only increase. International students, mostly Canadians studying abroad, are increasingly trying to do electives in Canada in the hopes of matching back.

Unfortunately, when we had the expansion of medical trainees, we didn't have an equal expansion in medical training sites. Most programs simply got bigger. Some efforts were made - NOSM opened up and satellite campuses opened up at many existing medical schools. These take advantage of larger (formerly) community hospitals to open up additional learning opportunities for medical students. Unfortunately, residency spots have not adjusted as quickly - with the exception of NOSM and many family medicine programs, there are only a handful of residency spots in these satellite campuses.

The optimistic side is that this situation should stabilize soon. No one is considering a further expansion of medical spots and there's rumblings that a decrease may be in order (no plans as of yet, to my knowledge). Residency spots have slightly declined and there's been a slow redistribution of spots to peripheral centers. There are only so many elective spots to go around, even if there are more and more interested international students, while schools are generally pretty careful about not giving those out frivolously.

It's a lesson in properly planning medical training - with such a complex system, all aspects need to be considered. Our current decision-making process is fairly fractured, with different actors responsible for different parts of the training process. Strong communication between these groups is vital moving forward.

Physician Names

I find it kind of interesting what physicians are called in the hospital, especially at various stages of training.

Residents are always called by their first names. Always. They've got the title "Dr." at this point, but using it except in official documents almost never gets used. The odd time I'll see a resident introduce themselves with the "Dr." title to patients, mostly to emphasize that despite looking young, they are in fact a doctor who will be responsible for their care, but it's not all that common. The trend I'm noticing is that particularly young-looking physicians, especially shorter women, do this more often, I assume to ward off the unfortunate assumption many patients will make that this person is their nurse or a medical student, not their doctor.

Fully-trained physicians almost always introduce themselves by their title and last name. Residents generally address them by their title, though there are certainly exceptions, especially in small programs. Nurses tend to move from title and last name to first name as they get older, which I think is a decent way to subtly convey seniority and keep physicians from getting too big of a head. After what is often 20 years of working, these nurses have more than earned the right to address their physician colleagues the same way those physicians address them (though it should arguably be equal from the start).

What I find especially interesting is how fully-trained physicians are referred to among residents and non-physicians. The first name seems to be used for physicians who are particularly liked, once again conveying a degree of familiarity. But the first name is also often used for physicians who are particularly disliked, almost as a way to knock them down a peg. Physicians who are neither loved nor hated get their title and last name used.

Fellows are another interesting case. In most cases, they're fully-qualified physicians, even though they're still in training. They've passed their certification tests, they can practice independently. Yet they're pretty much always referred to by their first names.

Anyway, nothing overly meaningful, just an interesting sociological pattern in the complex culture of medicine!

Wednesday 28 October 2015

On-Call Thoughts

Random thoughts from the middle of the night on-call:

1) Call rooms are like mini-hotel rooms and I love them. They're not much (pretty small, not overly fancy), but just the fact that they have a bed, a bathroom, a place to plug the phone in, and some privacy is awesome.

2) Call in Peds is completely different than call was in OB. OB call was basically just working at night - sleep was an unexpected luxury. Peds call still involves a fair bit of work, but sleep is more plentiful and much easier to predict.

3) The city looks oddly serene at nearly 3 am. My call room has a window and it truly looks like the whole place is asleep.

4) While maybe not the best idea, taking advantage of a middle-of-the-night wake up to do some homework feels oddly productive, though I'm not sure I got as much learning out of my efforts as I should have!

Saturday 24 October 2015

Stressing Out About Electives Choices

I mentioned previously that my electives choices are coming up in a few months, faster than I expected. I am stressing out about them, way more than I probably should be. I can't even start to make my choices for electives yet, but I've reached a near-obsession state about planning them.

Here's my basic conundrum: do I choose electives to maximize my chances of getting my preferred spot in the CaRMS match, or do I choose electives to maximize my learning? In the end, it will be a balance of both, but how far to go down each path is giving me pause. All of this is complicated by the fact that I haven't yet chosen what my target specialty will be, though I'm getting closer.

Nothing has yet to really grab me as a must-do specialty though this isn't too surprising as I've always been leaning towards a generalist role in one way or another. There are bits of each specialty I've seen so far that I enjoy, but nothing that hits me overall as uniquely interesting. What has become clear is that I value having a degree of control over my career - location, practice type, hours, that sort of thing. (This makes Family Medicine a rather attractive choice, given its excellent job market, flexible practice option, wide scope of practice, and shorter residency. I'm not set on it quite yet, and I still have some reservations about the field, but the pros of Family Med are definitely starting to outweigh the cons)

Anyway, back to electives. I have 16 weeks to work with, essentially eight 2-week stints (or perhaps one 4-week and six 2-week rotations). I'd like to do at least 8 weeks in whatever specialty I'd think of ranking first, if only to get a sense of what programs are like across the country and to maximize my chances at a good reference letter. Ideally these would come earlier in the rotation, before I have to submit my CaRMS documents. That leaves 8 weeks or less for learning, mostly on the back-end of my electives time.

But, then I think, maybe more time in the main specialty is necessary to maximize chances of matching to a place I'll like. After all, in every program I'm thinking about, I have more than 4 programs that I think would be good fits. Doing some "learning" electives within that specialty could be useful too, particularly in areas I'm not too keen on matching into (like Nunavut! Sorry Nunavut, you're really interesting, but my dog would probably freeze up there...).

And then I go back again, thinking more learning time might be best, considering most specialties I'm looking at aren't that competitive. Some rotations I may never get a chance to see again, such as Dermatology, even though I have zero interest in becoming a Dermatologist (I've quickly learned skin stuff pops up all the freaking time and most physicians aren't that good with these issues). I could take a bit of a gamble on myself - most people do match to their top 3 programs anyway - and hope that I have enough exposure between my clerkship experiences and my electives to find a good fit. Whatever specialty I decide on, if there's a choice between improving my capability as a physician and advancing my career, I'd rather pick the former than the latter - if I can still land a career I'm reasonably happy with.

Anyway, you see my indecision, before I even have a decision to make. Fingers crossed the next few months provide some clarity here!

Monday 19 October 2015

Public Opinion on Resident Work Hours

Stumbled across this article while researching a completely unrelated topic. Basic idea is that public opinion on resident work hours is rather strongly in favour of suggested restrictions and even is in favour of far more restrictive work hour limits. American-focused, but still relevant here in Canada.

I'm not a huge fan of making policy decisions - in medicine or otherwise - based primarily on public opinion. After all, people can make poor decisions and large groups of people are not guard against poor decision-making. More specifically when it comes to resident work hours, the public probably lacks a degree of perspective necessary to formulate a well-informed viewpoint.

However, the disparity is striking, and demonstrates how out-of-touch the practice of medicine is with the rest of society. While physicians debate the merits of an 80 hour average week, with more than a few physicians coming out strongly against such restrictions, the majority of non-physicians would be in favour of a 60 (or even 50!) hour average week with 80 hours maximum in a week. These opinions were fairly broadly-held, not dependent on demographics or ideology.

What's currently being discussed in medicine in terms of work hours borders on what "normal" people would consider insane. Perhaps these long work hours are necessary due to other factors. Still, even if it is a necessity, it's increasingly hard to maintain the pretense that these hours should be considered manageable by any common standard. Patients don't think their physicians should be working such long hours - if we continue with the current work weeks, we'd better have a very good justification as to why it's necessary they do.

Sunday 18 October 2015

Vote!

Tomorrow's election day. You should vote. It's fun, you will feel good about contributing to our great country, and the nice people at your polling station will often thank you for doing something that's in your own freaking best interests to do.

So go vote!

Location, Location, Location

Faster than I expected, I'm starting to look at my 4th year electives. It's tough - there's not much time to work with, a lot of uncertainty about what kind of elective I can get, or even what electives I want to get. Not knowing exactly what specialty I want yet makes it that much more challenging...

Anyway, the reason I bring this up is that I've increasingly become aware of how difficult it is to control where you live when doing your training. I've always been told that one of the best ways to ensure the career you want is to be flexible about location. Be willing to move anywhere in the country and your chances of getting your first choice specialty are very high. Be willing to move anywhere in the country and you'll get the fellowship you want, or the job you want after that.

I'm willing to move. And I'm not particularly interested in the major city centers (Toronto, Montreal, Vancouver) that tend to be uber-competitive, so my chances of ending up where I want to are at least reasonable. However, while I'm willing to move if necessary, I'd rather not move around too much over the next few years. In some career pathways, moving 4 times within a decade, potentially halfway across the country, is very plausible. For example, both Internal Medicine and Pediatrics go for three years before their subspecialty matches, each of which are typically followed by a 1-year fellowship before finding employment. That's potentially one move for residency, one move for subspecialty, one move for fellowship, and one move for work. Four potential moves total, assuming no second fellowship or locum work, both of which are entirely possible.

Granted, staying at one institution between med school and residency, residency and subspecialties, subspecialties and fellowship, and/or fellowship and employment is often an option. Most students do their residency at their home schools, after all. However, staying put isn't always a possibility. Not every residency, subspecialty, or fellowship exists at every school. Jobs aren't always easy to come by in locations with residency programs. The programs that exist where I want to stay may not be high-quality or tailored to my needs. They may not want me as a resident/fellow/employee either.

That's giving me a lot of pause when it comes to considering a long-term career pathway. If I'm going to move for residency, I'd rather not set myself up to have to move for a subspecialty or for fellowships. That's easier said than done, especially outside the competitive large cities.

This realization is also exposing a fairly fundamental conflict in my career/life planning. I'm ambitious, but I also work to live, not live to work. Optimizing my career goals means moving, a lot. Optimizing my life outside of my career means moving as little as possible. I'm not sure how easily I'll be able to find that balance.

Yet, finding that balance is now the goal. As a plan my electives, I also start to set my career path in motion. I've only got 16 elective weeks to find locations/programs that fit me well, fit my family well, and have some desirable career options moving forward. These weeks are also my best opportunities to show those programs that they should want me in their programs. Choosing electives may be the first "career" decision I've truly had to make so far since starting medical school, and I'm just now recognizing what kind of an impact these choices might have. Fingers crossed I make some good decisions!

Saturday 17 October 2015

(Fake) War is H-E-L-L

So, just finished up a game of Laser Quest where I was the only person old enough to get a driver's licence (full disclosure, I was supervising one of the children there, wasn't just a weird old guy hanging out with a bunch of pre-teens). I destroyed those small children, beating the second place finisher by around 300 points and nearly doubling the score of the third place finisher.

Am I making a post just to brag about my superiority over children who can barely hold up their lasers? Well, mostly yes. I take an odd pride in my Laser Quest ability, and I don't care if they were 2 feet shorter than me, I crushed them!

But, the other point is that we all grow up too fast and doing kid stuff every once in a while is a whole lot of fun.

(Side point - the kids all had a good time, even the ones I wouldn't stop shooting. And the parents of the kids all had a good laugh when I somewhat sheepishly accepted my first-place scorecard while towering over all the other competitors.)

Monday 12 October 2015

Work Hour Restrictions

Continuing on with my recent theme of super-long hours in the hospital, partially for myself, but mostly for my residents, it's worth mentioning the big elephant in the room for Canadian residency programs: resident work hour restrictions.

Long work hours have been identified as a potential cause of a lot of problems in medicine, both for providers and receivers of that care. The obvious solution then is to have providers - in particular the overworked residents - spend fewer hours on the job. While most countries with similar residency systems have implemented some form of work hour restrictions, Canada has not outside of Quebec. As such, it remains a topic of rather passionate debate, with fairly strong, opposing viewpoints from those at all levels of training.

Canadian practitioners are most familiar with how work hour restrictions came to be in the US, which were first implemented nationwide in 2003. The initial impetus for this change came from the death of Libby Zion, who, under the care of two overworked junior residents, was given a medication that when combined with her normal daily medications, resulted in a life-threatening condition that was not caught and eventually resulted in her death. The argument for work hour restrictions was fairly straight-forward: tired residents cannot deliver optimal care, so capping their hours (along with other restrictions on the distribution of those hours) will lead to more rested, more capable residents who would minimize mistakes for patients. There is more than enough evidence to support the notion that overworked or exhausted individuals are not the greatest workers and are prone to mistakes

The other justification, not always mentioned prominently in the debate, was to maintain the health and well-being of those residents. After all, residents are people too, who shouldn't be worked to the point of exhaustion. There is also quite a bit of evidence that long work hours contribute to medical or personal problems.

The argument against work hour restrictions was equally straight-forward: experience is the only way to make a competent physician, so work hour restrictions mean missed learning opportunities and less-competent physicians. There is also a large body of evidence for this argument, particularly in surgical specialties. You can't be competent with a surgical procedure until you've done it over and over again, so missed opportunities to scrub in add up.

It's now been 12 years since the first round of American work hour restrictions went into place and they've received a fair bit of scrutiny. The result? On all three points of consideration - patient outcomes, resident fatigue, and resident competency - the answer seems to be... mmmaaaaayyyybe...? In all respects, there seem to be studies which say work hour restrictions hurt, some which say they help, some which say they didn't make much different. On the whole, the answer seems to be that residents provide the same level of care, are just as tired, and just as competent as they were before the work hour restrictions.

Many of these studies come with fairly significant problems. With strong opinions on the subject being rather prevalent, bias in study design or result interpretation is a major concern that is difficult to address. Another large limitation is that actual hours worked before and after is rarely investigated. Some studies simply looked at results before and after the work hour restriction policy was put in place, without considering what effect that policy actually had on hours worked. Others used self-reported hours from residents which, as later investigations demonstrated, were often falsified to make it look like programs were in compliance with the regulations when they were routinely going over limits. Hard to see a change in outcome without a change in inputs.

A further criticism was that the work hour restrictions were still fairly permissive - 80 hours per week averaged over 4 weeks was the major cutoff. That's an average of about 11 and a half hours each and every day of the week, including weekends - hardly a light schedule. There were some other restrictions, such as 10 hours off between shifts, shifts that couldn't be longer than 24 hours (with an additional 6 for handover/education), one day off every week (on average) that were meant to make things a bit more palatable, but we're still not talking anything close to a 9-5 or even 7-5 job with weekends off.

There are also a lot of confounding factors when it comes to studying these interventions, which haven't been well addressed in previous literature. First is the challenge of handing over patients. Medicine sucks at transferring care between practitioners - it's a major opportunity for errors. When residents are prevented from working long shifts, it leads to more transfers of care, and more opportunities for mistakes to happen. The obvious response here is "fix the transfers", but that's easier said than done, so it remains a valid confounder. Another wrinkle in the intended effect of work hour restrictions is that residents don't always sleep when given more time. With 80+ hour work weeks, residents weren't just lacking sleep, they were lacking time to exercise, socialize, eat well, do domestic duties, spend time with their partner and/or children, whatever was important to them outside of medicine. When given the chance to spend less time at the hospital, sleep wasn't always the priority.

Unofficial duties also pop up outside the official work week. Every resident studies on their own time. Many participate in educational projects or research. "Homework" of a sort is pretty common. From my own experience, part of the challenge of dealing with 11 hour workdays is that I do 1-3 hours of studying, schoolwork, or EC tasks when I get home in the evening. In an environment where career opportunities are much less available than in the past, the impetus to go above and beyond, including using spare time, may eat up some extra time off.

When I started looking into the issue of resident work hours, my incoming opinion was that work hour restrictions were a painfully obvious solution to a painfully obvious problem. Given the available evidence, flawed as it may be, it's hard to maintain that view - work hour restrictions are not the disaster the detractors predicted, but neither is it a magic bullet. There are too many other factors to resident fatigue that need to be addressed in conjunction with work hours. We should be trying alternative approaches to reduce resident fatigue and evaluating them as intensely as we have work hour restrictions. In conjunction with or perhaps even in place of work hour restrictions, alternative approaches may provide the fatigue reduction many residents clearly need. It's hard to fathom that someone can work over 80 hours a week and be well-rested - there's simply no substitute for a good night's sleep - but I'm open to the idea if I can see some convincing evidence.

However, what are the alternatives? Safe transportation has come up, to prevent tired residents from driving home, but this is expensive and for many residents, costly in terms of time - a 15 minute drive home means more sleep than a 45 minute bus ride, for example. Another option, though not one I'd consider ethical, is medication. Some stimulants have been shown to improve wakefulness for tired workers, but sets a very dangerous precedent if it were to become compulsory. Past that, most discussions on this subject don't often provide realistic alternatives to improving resident fatigue. We should be open to any reasonable solutions to improving resident fatigue, but without workable alternatives to consider, effective implementation of resident work hour restrictions may be the only option for the moment, even if as a first step. Work hour restrictions may not be sufficient, and may not be optimally implemented in some jurisdictions, but they just might be necessary. Canada should consider an evidence-based approach to reducing resident working hours.

Friday 9 October 2015

My Amazing Residents

I'm getting towards the end of my first rotation. Something that deserves says - residents are awesome.

I've been hating the long hours - they work longer hours.

There's been a ton for me to learn in a short period of time - they have more to learn.

It's challenging to work and learn under others' directions, subject to their somewhat inconsistent whims - residents not only experience the same, but they teach us, having to adapt to our personalities and learning needs, all at the same time.

And they've been nothing but pleasant to me the whole time. They've often gone out of their way to teach me new things, or to get me in on useful clinical opportunities, or to let me practice a skill. So I wanted to take a quick second to send out a big "thank you" to all the residents who have helped me and tolerated my ignorance thus far. It really does make a difference.