Egg On My Face (Hockey Edition)

So, after claiming this was buyer's market before the NHL trade deadline, the actual market is proving me very, very wrong.

Toronto only got a middling return on Cody Franson and Mike Santorelli, but other trades have generated fairly strong returns. Winnik, Jagr, Sekara, and Timonen fetched far higher of a price than I would have expected (especially Timonen). Only Bergernheim came in below price, and that was a fairly unique situation.

How do I explain my failure? Well, more buyers popped up than expected. LA, Minnesota and Winnipeg went from being tentative buyers to being all the way in. Pittsburgh and Chicago made moves to improve their post-season chances despite being in relatively poor position compared to previous years. I'm guessing other buyers have been shopping around but have other targets or weren't willing to pony up as much for the pieces that were already moved.

None of this changes that I was wrong, but it's been fun to see how I got things wrong.

Conference Time

I'm at a conference, getting ready to present some of the research I've done over the last year or so. I love presenting my work and hearing the work others have done. I've already had a chance to hear about some fairly interesting research being done across Canada - and I really hope people find my research worthwhile.

That said, I hate conferences. This one is held at a very nice village out in the middle of nowhere. I drove for 7+ hours to get here, not including breaks for food and sanity. The plumbing has been problematic and so we've lost water several times so far. And everything is crazy expensive.

It'd be a nice place to go for a vacation, not all that ideal for doing work which, of course, I still have plenty of.

Is there any way to do the exchange of ideas in a conference without conference-level expense or hassle?

Specialty Popularity

After my little rant about how specialty competitiveness has influenced my thinking on what specialties I want to pursue, I got to thinking about what makes specialties more of less desirable to students.

The short list of factors is fairly obvious:
- Clinical activities
- Academic interest
- Lifestyle
- Job availability
- Money
- Non-clinical activities (research, teaching, paperwork, etc.)

Desired clinical activities, non-clinical activities, and academic interest really depend on the individual, but the other three factors are a bit more universal. Most people want to get a job easily in a location they want, to be paid well, and to work less than what most physicians end up working.

Right now, the highly competitive specialties are Plastic Surgery, Dermatology, Emergency Medicine, and Ophthalmology. Dermatology hits all three of those universally-desired characteristics. It pays well, jobs are everywhere, and it has a reasonable lifestyle. Emergency Medicine pays less and shift work isn't for everyone, but it also has good job availability and low hours overall. Plastics pays well, plus it has a better job market and lifestyle than most surgical specialties (though probably worse on both fronts compared to non-surgical specialties). Ophthalmology is a bit of an outlier - terrible job market, but the work load isn't horrible and the pay is incredibly high.

So, those highly competitive specialties largely fit the mold.

When we look at the more moderately competitive specialties, however, things start to change. Many surgical specialties remain reasonable competitive despite a complete lack of desirable jobs and a frankly horrible lifestyle. The pay is pretty good, however. OBGYN is in somewhat the same boat, trading a slightly better lifestyle and job market for a slightly worse salary in most parts of the country. Radiology has good pay, but the lifestyle is not what it used to be and the job market has not been great in recent years. Pediatrics has reasonable job opportunities and lifestyle, but low relative salary. Anesthesiology is about the only moderately competitive specialty that has a good job market, good salary, and good lifestyle.

Contrast this with the minimally competitive specialties. Family and Psychiatry have plenty of jobs and pretty good lifestyles, but generally low compensation. Internal Medicine is a bit more mixed and highly dependent on subspecialty, but overall lifestyle is decent, the job market is alright, and compensation is average-to-low (subspecialties with higher pay tend to have poor job opportunities). There are also a few small fields with poor job opportunities, good lifestyles and variable pay.

Interestingly, the most predictive factor for determining specialty competitiveness seems to be money. Only pediatrics and emergency medicine really break the mold, being more competitive than their average compensation would suggest. Lifestyle and job opportunities seem to matter to the extent that specialties of roughly equal pay are more competitive when they have these elements, but the correlation is much weaker.

Of course, personal factors matter, as does the relative number of positions for each specialty. Surgery is cool! There may not be jobs in many surgical specialties and an overall poor lifestyle, but students still want to do it. On the flip side, family medicine may not be competitive, but it sure is popular - it's just in such high demand from patients that there's little fight for family medicine residencies. Likewise, emergency medicine may be competitive simply because the number of residency positions is needlessly low.

Anyway, apologies for the rant - just needed to spell those thoughts out in writing.

Educational Dogs

Most people have heard of therapy dogs for patients - I'd like to propose educational dogs for teaching. Our class has a number of people with dogs, myself included, and one of my classmates has a little dog that comes to class every once in a while.

It's great - the dog is very well behaved and provides a nice distraction without taking much away from the lecture. Plus, it's an adorable dog!

Anyway, we were in class this week and he started barking. First time I've heard this dog really bark. The lecturer could have gotten annoyed or upset at the dog for interrupting their class, or at their owner for bringing it, but instead, they immediately quipped "See, even he thinks [insert point lecturer was making] is important!"

The whole class laughed, everyone woke up a bit, and the lecture continued without missing a beat. That's how to do education right. Sometimes, in both education and medicine, we get too caught up with etiquette and proper procedure. Having a tiny dog running around the classroom is not proper procedure for a lecture. And yet, it was an improvement having him around.

We get too worried about not doing something wrong, that we forget to stick our necks out a bit to do something right, even if it's as inconsequential as having an educational dog.

It's That Match Time of the Year Again!

The CaRMS match day is approaching. I'm still a few years away from that, but since I've been compulsively planning for that day since even before I got my acceptance to Med School, it's still a day I take note of. This year I'll have actually worked a bit with some of the people in the match, so I've got my fingers crossed it turns out well for them.

More selfishly, I like to see the trends in the match statistics. Some specialties are getting more competitive, some less competitive. Which ones are and why can tell you a lot about where the medical field is going and how its perceived at the undergrad training level. More importantly, it can indicate what kind of competition I'll be facing for the specialties I'm interested in.

I realize this shouldn't matter - I'll do my best and if I get my first choice great, if not I'll be satisfied with my backups. However, the competitiveness of a specialty has, oddly, factored somewhat into my decision-making.

I'm very wary of pursuing overly competitive specialties. I'm an ambitious person, I work hard, and I'm not afraid to fight for a career path I want. However, I want that fight to against problems, not people. Highly competitive specialties attract highly competitive people. I like to think medicine is a collaborative enough enterprise that you don't see too much backstabbing or other sorts of power plays where one person wins and other people lose, but I know that it does happen and happens far more often when students are going for competitive specialties. More than that, there's a certain level of one-upmanship. Every time your competition does something noteworthy, you have to do something more noteworthy (or better yet, do noteworthy things first). That approach to a career is exhausting. Even beyond simply matching, when you're in a field with competitive people, the competition never stops. There's always a research position, a fellowship, a potential job opening to fight for. I've got enough pressure to do my best, both external pressure and internal pressure. I want to routinely push myself to my limits to be a productive, effective physician. But I do have limits and don't want others to push me beyond them. I've seen too many unhappy physicians who are working beyond their limits.

By the same token, I'm somewhat skeptical of completely uncompetitive specialties. I worry that there are reasons students avoid these specialties that I haven't considered. I worry that my colleagues in these specialties will be less competent than those in other specialties. I worry these specialties won't be challenging enough, won't be rewarding enough or, to my great shame, won't be prestigious enough.

As an aside, having a more prestigious job is like winning a pissing contest - you satisfy your ego, but it's ultimately meaningless. Yet, like so many medical students, I have an ego that just won't shut up, even when I'd like it to.

So, my first choice of specialty is currently one that is only moderately competitive. You have to do more than apply to get in, but no one seems to be throwing elbows to get matched to it either. Obviously there's more to my interest in this specialty than historical CaRMS match rates, but I do sometimes wonder how much of that interest is affected by rather superficial judgments like the specialty's CaRMS match rate.

Pharmaceutical Marketing to Physicians

Ok, first things first.

I commented on how the NHL was a buyer's market, and lo-and-behold, the Leafs just shipped out two of the highest-value rentals for a relatively low return: a low-first rounder, essentially. Olli Jokinen was added simply to free up cap space in a way Toronto wouldn't mind, while the prospect, Brendan Leipsic, is far from certain to make NHL. He seems to have some offensive talent, but is an undersized third rounder. Leipsic isn't nothing, but it's a small consolation prize.

It's a deep draft, a low-first rounder definitely has value, but not that much more than a second rounder and certainly not more than two. Santorelli was worth a second round pick. Franson was worth a second round pick, if not more. If the trade the Leafs made was all they could get for those two, then it really is a buyer's market - or the Leafs management are idiots.

Alright, medicine-y stuff.

John Oliver's been on fire when tackling absurdities in the American social order and his most recent spills into Canadian society.

Pharmaceutical companies are some of the most profitable businesses in the world, certainly one of the most profitable in the health care system. Even in the US, where insurance companies are roundly vilified, they're not the ones with the substantial profit margins - pharmaceutical companies are. I doubt that's quite as true here in Canada, but nevertheless, drug companies make money - and they rely on physicians to do it.

The kind of practices in John Oliver's piece are present in Canada. Lunches and free samples in exchange for presentations by pharmaceutical companies are common. I've personally seen a physician try out a medication on the spot, in front of a pharmaceutical rep, and immediately become convinced of its efficacy (its effect was cosmetically apparent and, in fairness, it did appear to be working).

The justifications for these gifts are wide-ranging, but typically fall along the same lines: drugs help people, free samples are great for low-income patients, and while physicians may be compromised by their relationship with pharmaceutical companies, the individual physician giving these justifications isn't. The first two items in that list are true in many cases, the third... it might be true for a few physicians, but there's plenty of research that shows it's not true for most. That's why pharmaceutical companies spend so much  marketing to physicians. It might not work on everyone, but it works on enough of them.

It's a practice that needs to stop.

Vaccines

There's a lot of chatter, both in Canada and worldwide, about vaccinations. The spotlight is heavily on anti-vaccine proponents and parents, while those parties are pushing back against that criticism.

To top it all off, last week the Toronto Star ran what many in the scientific/medical community are describing as a tone-deaf scare piece lacking context or scientific merit. The Star's initial response ranged from nonsensical to arrogantly dismissive, but they have since printed a rebuttal piece put forth by medical experts and admitted fault in the presentation of the piece, while still defending the substance of it.

A few comments on the state of the discussion:

1) Vaccines - at least the recommended ones - work.

Full stop, vaccines work. Any piece on vaccinations that doesn't include something along these lines somewhere is simply wrong. MMR works. Gardasil works. The flu shot works. They all work to reduce the incidence of the diseases they're meant to vaccinate against.

2) Vaccines are safe, by any reasonable definition of that word.

Most reactions to vaccines are annoying but benign. No one likes redness, swelling, or tenderness around their injection site, which is the most common reaction to vaccines. A self-limiting fever or muscle pain can also occur with some vaccines. These aren't fun, but no one's in real danger from these reactions.

In some vaccines, there is a very small chance of an allergic reaction, of fainting, or having a seizure. These are serious concerns, but they are very rare and people are generally asked to stay in the clinic in case something like that does occur. These rare side-effects can be managed, which is why it's advised that people stay in whatever clinic gave them the vaccine for 15 minutes or so, just in case that happens. The chance of long-term disability or death from these events is highly unlikely if managed properly.

More serious events have been reported. However, their incidence rate is so low that it's uncertain that the vaccine played any role. More importantly, even if they did play a role, there's a greater likelihood of that person being struck by lightening than experiencing one of these debilitating side-effects.

I feel pretty safe walking around, even though I might be struck by lightening. Vaccines are safe.

3) Not all vaccines are equally effective.

While all the recommended vaccines work, not all of them work as well as we'd like them to. The MMR vaccine is very effective. Gardasil works well against a few select strains of HPV and those strains are certainly the ones we'd most like to protect against, but there are other strains of HPV that it doesn't protect against. The flu shot has variable effectiveness each year, though even in the worst years, does do a reasonable job of reducing the chances of catching the flu.

Despite the variable effectiveness, everyone should have all these vaccines. They all protect against diseases nobody wants and (see above), they're safe. Still, it's worth acknowledging that not all vaccines are created equal.

4) It's ok for parents to have concerns about vaccines.

Being a parent is scary. You want the best for your children and there's a lot of conflicting information out about virtually every subject. Vaccines are no exception. It's reasonable for parents to have concerns. These shouldn't be dismissed, and it shouldn't be denied that vaccines do carry a risk, albeit an incredibly small one. Parents listen to reason when they feel they're not under attack. The best advocates for vaccines take their time with resistant parents, explain their position without accusing the parents of doing something wrong, and are pleasant but persistent. They don't accept the parent's conclusion, but do accept the parent's motives - which, in the vast majority of cases, are to do what's best for their children.

The worst advocates for vaccines kick the kids of non-vaccinating parents out of their practice. They give up the only element of influence they have over non-vaccinating parents: a sympathetic ear from a medical expert interested in their children's well-being.

5) Authoritative sources - physicians, professors, the media - should be held to a higher standard.

The Toronto Star is getting piled onto because they're a visible, credible voice in this discussion and they got things wrong. Very wrong. Melody Torcolacci, a professor at Queen's, is under fire for promoting unsubstantiated views on vaccines in a university course. A cardiologist in the US is being harshly criticized for taking an anti-vaccination view.

I'm in full support of the unyielding criticism of these actors. These sources have a responsibility to tell the truth and should know better than to present falsehoods as fact. Some even stand to profit off these views, by spreading fear without justification. Concerned parents aren't the problem - the people making a living off disseminating fear and doubt without evidence are.

Friday Afternoon Tests

Anatomy bellringer this afternoon. Anatomy's arguably my strong suit and I've enjoyed this block, but you never know where you stand until you're tested. There's not much I've missed on my practice tests, but I still feel only moderately prepared for this one. Could be interesting...

Hockey!

Trying to keep this blog mostly about health care and medical school, but hey, I'm Canadian, I have to talk about hockey sometimes!

The NHL's trade deadline is approaching with a lot of speculation and, aside from a blockbuster between Winnipeg and Buffalo, there hasn't been much movement. This year has been touted as a potentially active trade deadline as there are number of mid-to-high profile free agents coming up as well as more than a few teams trying to do a top-to-bottom rebuild. Buffalo, Carolina, Ottawa, Arizona, and Toronto are all doing an overhaul. Edmonton and New Jersey should be as well, though they seem less eager to make the necessary changes.

Yet, the fact that there's high interest in selling doesn't mean there's a high interest in buying to match. Some playoff teams are limited by the salary cap (Boston, Chicago). Several are in the midst of a rebuild and unwilling to give up anything major for a rental player or another team's rejects (Winnipeg, Calgary). A few teams are skeptical about their playoff chances with their current core and probably won't make any real sacrifice to go deeper in the postseason (Vancouver, San Jose).

Right now, I see Detroit, Montreal, Tampa, Nashville, and Anaheim as the major potential buyers, and none of them seem overly eager to spend much. They're all well set up for the next half-decade and they don't want to risk those bright futures. It's a buyers market.

For teams looking to unload assets, they may have to be prepared for a low return. Not a great position to be in for rebuilding teams.

MSK & Anatomy

We're in the midst of our MSK block, which is really, really heavy on anatomy. I find anatomy to be one of the more enjoyable subjects to study - it's relatively constant (at least at our level), it's applicable to clinical practice, it's a clearly structured subject, and there's tons of teaching material out there that's mostly consistent.

Basically I feel like I'm learning something valuable, that will still be valuable decades from now, and since I can basically pick my method of learning, I can do it in the way I find most effective/efficient. That's more than I can say about most subjects in pre-Clerkship. This hasn't been an easy block - like I said, there's a lot of anatomy - but I'm going to miss it when we move onto other subjects.

Physician-Assisted Suicide in Canada

The Supreme Court of Canada dropped a bit of a bomb on the medical community last week by striking down a complete prohibition against physician-assisted suicide and giving legislatures and physician colleges a year to respond. This reverses a previous decision over 20 years ago effectively upholding such a ban, but it was generally expected that such a reversal would happen.

What wasn't expected was how strongly the SCoC sent the message that such a ban was not justified by the current legal framework in this country. The previous decision was 5-4 in favour of a ban. This decision was a full 9-0 against a ban. More than that, all nine justices appear to have had a hand in writing the decision. That's rare and usually done to make a statement. Supreme Court justices are busy, so when they make a decision, usually one author writes the opinion of the Court and everyone who agrees with it signs their name and that's about it. For a 9-0 decision to occur, all nine justices had to agree strongly enough to each claim partial authorship of this decision. That's virtually unprecedented for such a controversial decision.

Yet, was this really a controversial decision? Opinion polls put support for physician assisted suicide somewhere in the 80% range. That's about as favourable an opinion as hockey gets, and this is Canada!

Alright, there is some opposition from some fairly important groups. There's a range of opinion, but I'll break the opposition into three main groups.

First, conservatives, particularly religious conservatives. Physician-assisted suicide is popular in all provinces except Alberta, where opinion is fairly split. Now, the federal Conservative government is taking a cautious approach to this ruling, so we'll see where they ultimately stand, and at least a few Conservative MPs are supportive of this decision, Steven Fletcher being the most outspoken one. Yet, conservative groups and individuals are among the more vocal ones in opposition to this ruling for a variety of reasons.

Second, some advocacy groups for the disabled or elderly. Again, this isn't a unanimous viewpoint, but the fear from some is that this decision, or decisions made down the road, will result in the disabled, elderly, or infirmed will be pushed into death against their will. Experience from other jurisdictions provides comfort that this can be protected against, but this is understandably a major concern for these groups and some of those they represent.

Lastly, physicians. I think this is why the Supreme Court's decision could be considered controversial - it has broad support from Canadians in general, but physicians are conflicted. Only very recently did the Canadian Medical Association change its official stance on the subject from being in opposition to a more neutral one. I've already seen some of that divide first-hand - some physicians are supportive, many are permissive, but more than a few are opposed. The reasons for this split from population opinion are many, but the two main ones I've heard concerns worries that the current system is too prone to allow mistakes which would be unacceptable when it comes to intentional deaths, and simple discomfort with the notion of  physicians being part of intentionally contributing to the death of a patient.

The concerns of advocacy groups for the disabled and of physicians helped support the earlier, 1993 ruling upholding a ban on physician-assisted suicide. Part of the reason the Supreme Court decided otherwise in this case is due to the emergence of evidence from other jurisdictions that indicates these concerns can be addressed without a total ban on the practice.

My personal views on the matter are hesitantly supportive. We already do so much in medicine where our decisions result in death in accordance with a patient's wishes. We couch those instances in excuses - typically that we're respecting a patient's right to refuse care. Ultimately though, the patient has a choice between living in a state they would consider unacceptable or dying, and when they choose dying we act accordingly and the patient dies. We denied that choice to patients whose illness doesn't naturally progress to death as quickly as they'd like, but medicine is at its core about defying the natural course of disease.

I am somewhat uncomfortable about the prospect of enabling death rather than fighting for life, but I have misgivings about a number of elements to medicine that I'm less-than-comfortable with. That doesn't mean I won't participate in those elements. I took an oath to help my patients and that means, at times, doing things I'm uncomfortable with if it will help my patients. In some rare cases, that includes facilitating death. I'm not excited about it, but I'm willing.

Finally, I share the concerns advocacy groups and many of my colleagues have about the process. I want to see some very stringent restrictions on this practice to ensure it is not abused. I'm hopeful, given the Canadian Medical Association's tacit willingness to address this issue that physician will present a balanced viewpoint on this. I'm also hopeful that the Conservative government, ideologically opposed to physician-assisted suicide but responsive to public opinion, will put strong restrictions in place to appease their base without alienating the wider electorate.

More than anything, I'm happy this discussion is finally happening among those who hold the most power in this debate - namely physicians and politicians. For too long, this was a topic not to be discussed. Now, we have to talk about it.

Time Management

There's a lot going on a school right now - too much. All my ECs are ramping up their time demands, I've got a conference coming up (which I haven't prepared for yet), we just got through a bunch of preparatory test (fake tests not worth any marks), and the real tests are coming soon.

By the end of this week I need to write two essays, start/finish studying for a hefty anatomy test, prepare my talk for that upcoming conference, start preparations on a weekend-long educational session in the summer, schedule an evening session for one of my ECs, and get the ball rolling on a major initiative for another one of my ECs.

Oh, and I probably need a haircut...

It's going to be a fun week!