Quick addition to the previous post. It has to be mentioned that the effect of this reduction in Ontario CMG residency spots won't just fall on Ontario CMGs. Residency positions are up for nation-wide competition aside from Quebec, which is technically in the same pool but the language requirements separate them for many CMGs. A lot of non-Ontario CMGs do their residency in Ontario and a lot of Ontario CMGs do their residency elsewhere. So the pain gets spread around a little bit.
In addition, CMG spots that go unfilled in the first round go to the second round, where IMGs can compete for them. Depending on how well CMGs respond to this tightened residency market, the number of spots in the second round should go down (though likely not by 50). That leaves fewer opportunities for IMGs.
All told, because these are CMG spots in Ontario, Ontario CMGs will still be disproportionately affected. The change for the average Ontario CMG should be fairly small. 50 spots is only 5% of the total available, so the large majority of Ontario CMGs will still get a residency position they find desirable, just as they did this year. Still, there will be some impact and Ontario CMGs won't be the only ones affected.
Friday 31 July 2015
Ontario Ministry of Health Reduces CMG Residency Spots
So, a bit of a shocker - over the next two years, Ontario will reduce the number of residency spots in the first round of CaRMS for CMGs by 50 per year. This coming cycle will see 25 fewer spots than this year, with another 25 seat reduction in the subsequent cycle (my cycle) for a total of 50 fewer spots.
This has been done without a similar reduction in the number of graduating medical students, which will be more-or-less static for the next 4 cycles, as each one of those cohorts has started or been accepted to their MD program. This is also being done without much warning. In fact, the only information about this change has come from the organizations representing Ontario MD students on the provincial and national levels, the OMSA and the CFMS. The people in these organizations deserve full credit for publicizing this change as soon as they could.
Since we haven't been given an official release from the Ministry itself, many of the details are still unknown or unsettled. Some information has come out through back-channels, but these may not be final or entirely accurate. The information I've been told indicates that these cuts will hit all schools in Ontario proportionately and will fall primarily on primary care residencies. We also don't know why the Ministry believes this change is necessary or beneficial. The intent seems to be to reduce the ratio of Ontario MD grads to CMG spots in Ontario from it's historical target of 1:1.10 to 1:1.05.
If that was indeed the goal, then this change wouldn't be too harsh for Ontario CMGs. If the cuts were to residencies that were of lower value - either because the demand for physicians in that specialty has fallen or the need for physicians in the region served by that residency program is minimal - then this would be a sensible move. It would force Ontario CMGs to accept less desirable residency positions, but there would still be some slack in the system and Ontario CMGs would be better able to serve Ontario patients.
Yet, these cuts seem to be made without much regard for which residency positions get the ax, or their value to Ontario patients. Hopefully when details come out I will be proven wrong, but the indications coming out aren't encouraging.
In addition, while the target ratio may have been 1:1.10, the actual ratio last year, as far as I can tell, was lower, at only 1:1.06. Removing 50 spots lowers that ratio to just below 1:1.01, or less than 1% surplus of CMG spots in Ontario relative to new graduates. This change doesn't just reduce the slack in the system, it eliminates it entirely. The whole point to having some additional positions is to accommodate previous years' graduates who went unmatched, to provide some room for incoming USMGs, to allow for some movement across the country (CMGs can match anywhere in the country, not just their home province), and to provide some flexibility for CMGs based on their preferences. If the ratio falls to below 1:1.01, the number of unmatched CMGs will grow.
If they had reduced the number of medical students to retain a workable ratio (say, the goal of 1:1.05), then this would be a move that at least had some merit. It's expensive to train physicians, but training them halfway and them preventing them from going further for reasons unrelated to competence means a lot of wasted funding for their education.
I really hope that as details emerge, we'll be able to see the intent of this change and why this particular move was the best way to go. Still, based on what's come out so far, I don't see how this move is the optimal course of action for any party involved, including the Ontario healthcare system or Ontario government's bottom line.
This has been done without a similar reduction in the number of graduating medical students, which will be more-or-less static for the next 4 cycles, as each one of those cohorts has started or been accepted to their MD program. This is also being done without much warning. In fact, the only information about this change has come from the organizations representing Ontario MD students on the provincial and national levels, the OMSA and the CFMS. The people in these organizations deserve full credit for publicizing this change as soon as they could.
Since we haven't been given an official release from the Ministry itself, many of the details are still unknown or unsettled. Some information has come out through back-channels, but these may not be final or entirely accurate. The information I've been told indicates that these cuts will hit all schools in Ontario proportionately and will fall primarily on primary care residencies. We also don't know why the Ministry believes this change is necessary or beneficial. The intent seems to be to reduce the ratio of Ontario MD grads to CMG spots in Ontario from it's historical target of 1:1.10 to 1:1.05.
If that was indeed the goal, then this change wouldn't be too harsh for Ontario CMGs. If the cuts were to residencies that were of lower value - either because the demand for physicians in that specialty has fallen or the need for physicians in the region served by that residency program is minimal - then this would be a sensible move. It would force Ontario CMGs to accept less desirable residency positions, but there would still be some slack in the system and Ontario CMGs would be better able to serve Ontario patients.
Yet, these cuts seem to be made without much regard for which residency positions get the ax, or their value to Ontario patients. Hopefully when details come out I will be proven wrong, but the indications coming out aren't encouraging.
In addition, while the target ratio may have been 1:1.10, the actual ratio last year, as far as I can tell, was lower, at only 1:1.06. Removing 50 spots lowers that ratio to just below 1:1.01, or less than 1% surplus of CMG spots in Ontario relative to new graduates. This change doesn't just reduce the slack in the system, it eliminates it entirely. The whole point to having some additional positions is to accommodate previous years' graduates who went unmatched, to provide some room for incoming USMGs, to allow for some movement across the country (CMGs can match anywhere in the country, not just their home province), and to provide some flexibility for CMGs based on their preferences. If the ratio falls to below 1:1.01, the number of unmatched CMGs will grow.
If they had reduced the number of medical students to retain a workable ratio (say, the goal of 1:1.05), then this would be a move that at least had some merit. It's expensive to train physicians, but training them halfway and them preventing them from going further for reasons unrelated to competence means a lot of wasted funding for their education.
I really hope that as details emerge, we'll be able to see the intent of this change and why this particular move was the best way to go. Still, based on what's come out so far, I don't see how this move is the optimal course of action for any party involved, including the Ontario healthcare system or Ontario government's bottom line.
Thursday 30 July 2015
Clerkship - It's Coming...
Just got my first official clerkship schedule. I start with my OBGYN rotation, which I'm told is a good place to begin. Apparently it's just hard enough to get clerks used to the challenges of clinical medicine, but just short enough not to burn you out, especially at the beginning when we're all still eager and energetic.
Anyway, I'm excited and nervous. For the first time, Clerkship isn't just an abstraction - I have a real schedule, with my name on it and everything. Heck, I have a pager schedule! I still barely understand how a pager works!
I've done more than my share of clinical training in my previous career, so I know I shouldn't make such a big deal about this. Still, it feels different than my earlier training in many ways. I just hope I'm up to the challenge.
Anyway, I'm excited and nervous. For the first time, Clerkship isn't just an abstraction - I have a real schedule, with my name on it and everything. Heck, I have a pager schedule! I still barely understand how a pager works!
I've done more than my share of clinical training in my previous career, so I know I shouldn't make such a big deal about this. Still, it feels different than my earlier training in many ways. I just hope I'm up to the challenge.
Tuesday 28 July 2015
On Giving Advice About Medical School Admissions
I like to give advice. I like to give advice about any subject I feel I'm well enough informed upon to give meaningful and helpful information. I think that makes medicine a good fit for me since a lot of what a physician does is counsel patients or other health care providers. At my stage of training, I don't know all that much medicine, so there's not much I can competently advise on from a medical perspective.
So, I tried to stick to something I knew very well - how to get into medical school. Since I started my applications to medical school nearly 3 years ago, I've talked to dozens of people either in person or online about how to get into medical school, where they could improve their application and where they were fine. I suggested schools to apply to, schools that weren't worth applying to, and schools that might become an option with some additional work.
In the past 3 years I think - or at least, I hope - that the information and advice I have given has been helpful and accurate. Yet, as the next cycle of medical school applications starts up, I'm finding myself falling behind. I've forgotten some details about going through the application process. Some of those details have changed. Some aspects of applying which are fairly major have changed. Heck, the MCAT has gone through two versions since I wrote it. I'm still knowledgeable about the school I attend and I'm fairly up-to-date when it comes to the schools I interviewed at, but even that will start to fade the further I get from my time applying.
Point is that it doesn't take long for knowledge to disappear without use and applications to medical school are no different. Anyone in residency or beyond has information that is at least 4 years out of date. If you're looking for help with applications, it's tempting to call on an experienced physician, but chances are they know the least about how getting into medicine works today. The best sources are often the people who just got in, or are still trying to get in themselves.
So, I tried to stick to something I knew very well - how to get into medical school. Since I started my applications to medical school nearly 3 years ago, I've talked to dozens of people either in person or online about how to get into medical school, where they could improve their application and where they were fine. I suggested schools to apply to, schools that weren't worth applying to, and schools that might become an option with some additional work.
In the past 3 years I think - or at least, I hope - that the information and advice I have given has been helpful and accurate. Yet, as the next cycle of medical school applications starts up, I'm finding myself falling behind. I've forgotten some details about going through the application process. Some of those details have changed. Some aspects of applying which are fairly major have changed. Heck, the MCAT has gone through two versions since I wrote it. I'm still knowledgeable about the school I attend and I'm fairly up-to-date when it comes to the schools I interviewed at, but even that will start to fade the further I get from my time applying.
Point is that it doesn't take long for knowledge to disappear without use and applications to medical school are no different. Anyone in residency or beyond has information that is at least 4 years out of date. If you're looking for help with applications, it's tempting to call on an experienced physician, but chances are they know the least about how getting into medicine works today. The best sources are often the people who just got in, or are still trying to get in themselves.
Friday 24 July 2015
Research Ethics Boards
Stumbled across this post today. Research ethics boards fill an important role in ensuring we are not performing dangerous or exploitative research. Before ethics boards became the norm, there were more than a few instances of highly questionable, dangerous experimentation performed on humans, particularly in medicine. REBs serve as a guard against that kind of research.
However, those protections should be tailored to potential for harm and effective at preventing such harm. This is not the case with all REBs for all studies. My personal experiences with REBs have been mixed, but a large heaping of unnecessary bureaucracy and needless fiddling with formatting have been typical. In my worst experience, I spent 3+ months to get a survey approved after countless back-and-forth exchanges, only one of which involved making anything that came close to meaningful changes. And this was in the "fast track" review system.
Apparently, my experiences are far from unique and may be on the benign side. In all cases, I lost time and so my window to actually perform the research was significantly shortened, which I believe did negatively impact the quality of those studies. Still, the studies were completed largely in their intended format, so the main downside was an inconvenience for me. Others' have had meaningful research denied, interrupted, or invalidated because of REBs. On the whole, REBs add a major inefficiency to the research process and can put a major damper on research studies getting started or completed.
The book mentioned in the linked post apparently makes the case to abolish REBs entirely. I think that's extreme, because REBs do represent a medium through which research can not only be made safer, but stronger as well. Particularly in medicine, this is essential, as the quality of research is critical to its value to society at large and even small changes to many studies could make a meaningful difference in their quality. Still. changes need to be made to the structure, powers, and mandates of REBs to facilitate that process.
The first steps to improving REBs should probably concern funding and oversight. Without enough resources, REBs can't move studies through quickly or draw on the opinions of experts. There are still ways they could improve throughput and expertise without increased funding, but it was clear from my interactions that those organizing the REB I was interacting with had a lot on their plates. In terms of oversight, many REBs are the final say on research projects, regardless of whether their opinions are valid or helpful. Researchers, knowing that the whims of an REB can sink their projects and that they'd have little-to-no recourse, tread lightly around REBs, even if their recommendations are trivial (or worse).
What surprises me is the relative apathy universities have towards their own REB's functionality. Research is the lifeblood of most major universities - publish or perish exists for a reason. Yet there seems to be little willpower to address what seems to be a major inefficiency in the research pipeline.
I've been involved in half a dozen research projects over the past 4 years or so and I would like to continue having a hand in research through the rest of my career. It would be great we could retain the oversight REBs provide while reducing their burden on researchers.
However, those protections should be tailored to potential for harm and effective at preventing such harm. This is not the case with all REBs for all studies. My personal experiences with REBs have been mixed, but a large heaping of unnecessary bureaucracy and needless fiddling with formatting have been typical. In my worst experience, I spent 3+ months to get a survey approved after countless back-and-forth exchanges, only one of which involved making anything that came close to meaningful changes. And this was in the "fast track" review system.
Apparently, my experiences are far from unique and may be on the benign side. In all cases, I lost time and so my window to actually perform the research was significantly shortened, which I believe did negatively impact the quality of those studies. Still, the studies were completed largely in their intended format, so the main downside was an inconvenience for me. Others' have had meaningful research denied, interrupted, or invalidated because of REBs. On the whole, REBs add a major inefficiency to the research process and can put a major damper on research studies getting started or completed.
The book mentioned in the linked post apparently makes the case to abolish REBs entirely. I think that's extreme, because REBs do represent a medium through which research can not only be made safer, but stronger as well. Particularly in medicine, this is essential, as the quality of research is critical to its value to society at large and even small changes to many studies could make a meaningful difference in their quality. Still. changes need to be made to the structure, powers, and mandates of REBs to facilitate that process.
The first steps to improving REBs should probably concern funding and oversight. Without enough resources, REBs can't move studies through quickly or draw on the opinions of experts. There are still ways they could improve throughput and expertise without increased funding, but it was clear from my interactions that those organizing the REB I was interacting with had a lot on their plates. In terms of oversight, many REBs are the final say on research projects, regardless of whether their opinions are valid or helpful. Researchers, knowing that the whims of an REB can sink their projects and that they'd have little-to-no recourse, tread lightly around REBs, even if their recommendations are trivial (or worse).
What surprises me is the relative apathy universities have towards their own REB's functionality. Research is the lifeblood of most major universities - publish or perish exists for a reason. Yet there seems to be little willpower to address what seems to be a major inefficiency in the research pipeline.
I've been involved in half a dozen research projects over the past 4 years or so and I would like to continue having a hand in research through the rest of my career. It would be great we could retain the oversight REBs provide while reducing their burden on researchers.
Thursday 23 July 2015
Preparing to Match in CaRMS (Before Knowing What To Match Into)
This is a quick follow-up on the previous post. As I said, part of the anxiety about choosing a specialty is the fear that by the time you figure out which specialty you want to match into, you won't be a competitive applicant for that field. It'll simply be too late - all the other students who figured out this was for them will be too far ahead of you.
Here's the thing: the way CaRMS works for most programs right now, what you do in pre-Clerkship barely matters. Being involved in student groups or student leadership doesn't make much of a difference. Doing volunteer work doesn't make much of a difference. Since all of English-speaking Canada operates on a Pass/Fail system, pre-Clerkship grades don't matter (so long as you pass). Awards, scholarships, and other forms of recognition are nice, but won't make much of a difference.
Research can have an impact, but mostly for the highly competitive specialties. Some programs don't look at research at all. Others look at it, but it's such a minor factor that it won't matter for most applicants. Still more do consider research as a reasonably large component of their evaluation scheme, but their threshold for doing well in that category is pretty low - doing any sort of research in any field will largely satisfy the research component of their evaluation. Even for programs that do put an emphasis on research, who are asking for a project done in their specialty, this can be accomplished in third year - for example, a case study can go a long way.
Point is, even though research can matter, not having it in pre-clerkship, before you've figured out what you want to do, isn't a death sentence. If you want to do, say, Dermatology in Toronto, then yeah, you might lose out to the gunners who have been pushing for Derm since M1. Yet, for the vast majority of specialties and programs, there's nothing that must be done in pre-clerkship to be a competitive candidate.
My greatest fear coming into medical school was that I wouldn't have control over my own future - that I'd slip up somewhere and have to settle for a career in medicine I didn't want. Like many incoming med students, I searched high and low to find the steps I could take to maximize my chances of getting whatever residency I ultimately wanted. I pursued many activities to show that I was a productive, intelligent student, beyond the demands of school itself. I wrote papers, gave presentations, organized extra-curricular educational sessions, and helped plan nation symposiums (side note - are you a pre-med in London the weekend of August 22/23rd? The Western Student Ultrasound Symposium could use an extra volunteer or two! :p )
In all honesty, I could have sat on my butt these two years and largely ended up in the same spot.
That's a good thing. It means I had the flexibility to pursue activities I found valuable or interesting, rather than just the activities that would have affected my chances at a desired residency spot. It also means I could defer making a final selection about my specialty until I have more perspective, which I hope to get in Clerkship.
Bottom line is that it's alright to use your ECs to explore your interests, without worrying whether they'll be optimal when it comes time for residency applications. Chances are they won't matter much anyway.
Point is, even though research can matter, not having it in pre-clerkship, before you've figured out what you want to do, isn't a death sentence. If you want to do, say, Dermatology in Toronto, then yeah, you might lose out to the gunners who have been pushing for Derm since M1. Yet, for the vast majority of specialties and programs, there's nothing that must be done in pre-clerkship to be a competitive candidate.
My greatest fear coming into medical school was that I wouldn't have control over my own future - that I'd slip up somewhere and have to settle for a career in medicine I didn't want. Like many incoming med students, I searched high and low to find the steps I could take to maximize my chances of getting whatever residency I ultimately wanted. I pursued many activities to show that I was a productive, intelligent student, beyond the demands of school itself. I wrote papers, gave presentations, organized extra-curricular educational sessions, and helped plan nation symposiums (side note - are you a pre-med in London the weekend of August 22/23rd? The Western Student Ultrasound Symposium could use an extra volunteer or two! :p )
In all honesty, I could have sat on my butt these two years and largely ended up in the same spot.
That's a good thing. It means I had the flexibility to pursue activities I found valuable or interesting, rather than just the activities that would have affected my chances at a desired residency spot. It also means I could defer making a final selection about my specialty until I have more perspective, which I hope to get in Clerkship.
Bottom line is that it's alright to use your ECs to explore your interests, without worrying whether they'll be optimal when it comes time for residency applications. Chances are they won't matter much anyway.
Wednesday 22 July 2015
How To Pick A Specialty
Like many medical students or soon-to-be medical students, I suffer from periodic existential crises about what specialty I will end up going into when it comes time to become a resident.
Ok, "crisis" may be too strong a word, but choosing a specialty is arguably the most important decision of a physician's career, one which is largely irreversible, and so it's fairly anxiety-producing when the thought of "What kind of doctor should I become?" pops up. With some specialties being extremely competitive, that thought also gets mixed in with the fear of not getting the desired specialty when it's chosen. To help manage some of this anxiety, I started looking at my specialty choice in a semi-methodological way that, even if it doesn't give me a final answer, lets me feel like I have some control over my future.
I thought I'd share my process. It won't work for everyone, but I've found it helpful for my situation.
When I first got into medical school, I looked at every specialty. There are a LOT of them, particularly when you include sub-specialties that have their own unique features. However, it's the specialty that gets decided at the end of medical school, not the sub-specialty, so I figured I'd best start there. Here's the list of all direct-entry specialties in Canada:
Anatomical Pathology
Anesthesiology
Cardiac Surgery
Dermatology
Diagnostic Radiology
Emergency Medicine
Family Medicine
General Pathology
General Surgery
Hematological Pathology
Internal Medicine
Medical Biochemistry
Medical Genetics
Medical Microbiology
Neurology (adult)
Neurology (pediatrics)
Neuropathology
Neurosurgery
Nuclear Medicine
Obstetrics & Gynecology
Ophthalmology
Orthopedic Surgery
Otolaryngology - Head and Neck Surgery
Pediatrics
Physical Medicine & Rehabilitation
Plastic Surgery
Psychiatry
Public Health and Preventive Medicine
Radiation Oncology
Urology
Vascular Surgery
Wow that's a long list... How do you decide between 30 specialties?!
Well, the short answer is, you can't. At least, you can't make a truly informed decision - there's simply not enough time to fully explore every one of those 30 specialties while still being a competitive applicant to all of them. The good news is, making a fully informed decision isn't necessary and the final decision can wait. Most medical students settle on their eventual specialty sometime in Clerkship (3rd year for most students). A few figure it out earlier, in pre-Clerkship, and a few don't ultimately decide until 4th year, but 3rd year seems to be the most common. The majority of students match to their desired specialty and are happy with their decision, so that's quite reassuring.
Those two facts - that I can't (and don't need to) check out every specialty and that I probably won't make my final decision until Clerkship has led to the approach I describe now.
Basically, I started narrowing down the full list of specialties you see above you. This narrowed-down list became the list of specialties I could potentially enjoy practicing. Once a specialty was scratched off that list, that was it - that specialty was dead to me. Any crossed off specialty would be largely ignored. In the first year of medical school, I cut this list down to this:
Anesthesiology
Dermatology
Diagnostic Radiology
Emergency Medicine
Family Medicine
Internal Medicine
Neurology (adult)
Neurology (pediatrics)
Nuclear Medicine
Obstetrics & Gynecology
Pediatrics
Physical Medicine & Rehabilitation
Psychiatry
Public Health and Preventive Medicine
Radiation Oncology
Now that's a lot more manageable!
In my second year, I started crossing off specialties that had really failed to grab my attention despite a reasonable amount of exposure. They might have been fits, but they clearly weren't where I wanted to devote my energies. So, the list shrank a bit further:
Diagnostic Radiology
Emergency Medicine
Family Medicine
Internal Medicine
Nuclear Medicine
Obstetrics & Gynecology
Pediatrics
Physical Medicine & Rehabilitation
Going into Clerkship, that's where I stand, which makes the daunting prospect of choosing a specialty much more palatable.
In all honesty, I've probably cut down my list further than I need to for my stage of training. Again, most people decide their specialty in Clerkship, which has built-in clinical exposure to Family Med, Internal, OB/GYN, Peds, General Surgery, and Psych, so those can still be on the table for everyone. My program has mandatory short rotations through EM and Anesthesiology as well, which I believe is also the case for most programs in Canada, so those could stick around as well.
There's a reason those fields are mandatory training in Clerkship - besides giving an overall good grounding in medicine, last year about 83% of Canadian graduates matched into one of those 8 fields. Chances are you will match to one of these specialties too!
If there is a role for pre-Clerkship in determining your specialty, it's ruling in or ruling out those smaller specialties without built-in exposure in Clerkship. That's a much more reasonable goal than definitively locking down a single specialty early in the game!
Ok, "crisis" may be too strong a word, but choosing a specialty is arguably the most important decision of a physician's career, one which is largely irreversible, and so it's fairly anxiety-producing when the thought of "What kind of doctor should I become?" pops up. With some specialties being extremely competitive, that thought also gets mixed in with the fear of not getting the desired specialty when it's chosen. To help manage some of this anxiety, I started looking at my specialty choice in a semi-methodological way that, even if it doesn't give me a final answer, lets me feel like I have some control over my future.
I thought I'd share my process. It won't work for everyone, but I've found it helpful for my situation.
When I first got into medical school, I looked at every specialty. There are a LOT of them, particularly when you include sub-specialties that have their own unique features. However, it's the specialty that gets decided at the end of medical school, not the sub-specialty, so I figured I'd best start there. Here's the list of all direct-entry specialties in Canada:
Anatomical Pathology
Anesthesiology
Cardiac Surgery
Dermatology
Diagnostic Radiology
Emergency Medicine
Family Medicine
General Pathology
General Surgery
Hematological Pathology
Internal Medicine
Medical Biochemistry
Medical Genetics
Medical Microbiology
Neurology (adult)
Neurology (pediatrics)
Neuropathology
Neurosurgery
Nuclear Medicine
Obstetrics & Gynecology
Ophthalmology
Orthopedic Surgery
Otolaryngology - Head and Neck Surgery
Pediatrics
Physical Medicine & Rehabilitation
Plastic Surgery
Psychiatry
Public Health and Preventive Medicine
Radiation Oncology
Urology
Vascular Surgery
Wow that's a long list... How do you decide between 30 specialties?!
Well, the short answer is, you can't. At least, you can't make a truly informed decision - there's simply not enough time to fully explore every one of those 30 specialties while still being a competitive applicant to all of them. The good news is, making a fully informed decision isn't necessary and the final decision can wait. Most medical students settle on their eventual specialty sometime in Clerkship (3rd year for most students). A few figure it out earlier, in pre-Clerkship, and a few don't ultimately decide until 4th year, but 3rd year seems to be the most common. The majority of students match to their desired specialty and are happy with their decision, so that's quite reassuring.
Those two facts - that I can't (and don't need to) check out every specialty and that I probably won't make my final decision until Clerkship has led to the approach I describe now.
Basically, I started narrowing down the full list of specialties you see above you. This narrowed-down list became the list of specialties I could potentially enjoy practicing. Once a specialty was scratched off that list, that was it - that specialty was dead to me. Any crossed off specialty would be largely ignored. In the first year of medical school, I cut this list down to this:
Anesthesiology
Dermatology
Diagnostic Radiology
Emergency Medicine
Family Medicine
Internal Medicine
Neurology (adult)
Neurology (pediatrics)
Nuclear Medicine
Obstetrics & Gynecology
Pediatrics
Physical Medicine & Rehabilitation
Psychiatry
Public Health and Preventive Medicine
Radiation Oncology
Now that's a lot more manageable!
In my second year, I started crossing off specialties that had really failed to grab my attention despite a reasonable amount of exposure. They might have been fits, but they clearly weren't where I wanted to devote my energies. So, the list shrank a bit further:
Diagnostic Radiology
Emergency Medicine
Family Medicine
Internal Medicine
Nuclear Medicine
Obstetrics & Gynecology
Pediatrics
Physical Medicine & Rehabilitation
Going into Clerkship, that's where I stand, which makes the daunting prospect of choosing a specialty much more palatable.
In all honesty, I've probably cut down my list further than I need to for my stage of training. Again, most people decide their specialty in Clerkship, which has built-in clinical exposure to Family Med, Internal, OB/GYN, Peds, General Surgery, and Psych, so those can still be on the table for everyone. My program has mandatory short rotations through EM and Anesthesiology as well, which I believe is also the case for most programs in Canada, so those could stick around as well.
There's a reason those fields are mandatory training in Clerkship - besides giving an overall good grounding in medicine, last year about 83% of Canadian graduates matched into one of those 8 fields. Chances are you will match to one of these specialties too!
If there is a role for pre-Clerkship in determining your specialty, it's ruling in or ruling out those smaller specialties without built-in exposure in Clerkship. That's a much more reasonable goal than definitively locking down a single specialty early in the game!
Sunday 19 July 2015
Hockey Post
Time for an obligatory hockey post! Yes, please ignore these, I write them so I don't pester my SO with my random hockey thoughts. It's good for our relationship.
NHL Playoffs
I did pretty well with my predictions this playoff season except for one, tiny misstep: in every round except the finals, I picked the Chicago Blackhawks to lose. First round I went 7 for 8 with the Chicago series being my sole error. Well that went well... Anyway, big congrats to Chicago and bigger congrats to Toews, Kane, Hossa, and Keith, who all pretty much sealed their inductions to the HHOF with that cup win (the other three-cup winners from Chicago - Sharp, Seabrook, and Hjalmarsson - may deserve consideration as well depending on what else happens in their careers).
NHL Draft
Edmonton got the #1 pick... again... boo. In fairness, with the exception of Hall, none of their previous #1 picks really seem like true #1's, so I guess this is the hockey gods compensating them for that.
The draft choices pretty much went as expected. I was hoping Toronto would get Strome, mostly because he fits their needs better than anyone else who might have made it to #4, but Marner is a great consolation prize. Marner likely won't become the physical, two-way centreman that seems necessary to win a cup these days (Strome could), but he's got more potential than Strome and could easily become a premier winger. It's like getting Kessel minus some of the attitude problems. Coming out of London, Marner should have some defensive ability as well - the Knights seem to pound defensive responsibility into their players, even the offensively gifted ones.
Trades, Trades Everywhere!
Speaking of Kessel, decent return for him from Pittsburgh. Real win-win trade. Pittsburgh gets a real winger for their top-end centers, while Toronto gets about as good as they could get for Kessel, who they really wanted to get rid of anyway. I like the players Toronto got back, both of whom weren't living up to expectations in Pittsburgh but who have real potential moving forward. I'm glad they picked up Harrington. He'll never be a top-pair D-man, but he could easily be a solid second-pair player with the right motivation.
Boston got burned on Dougie Hamilton, shipping him off for a fairly poor return and seeing him ink a very fair deal with Calgary. Must have been something going on between the organization and Hamilton, or Boston made a very, very stupid deal. Good thing they made up for it with the Lucic trade, getting way more for him than they should have been able to get.
The goalie market got weird, with Lehner fetching far more than he should while Talbot got sold off for peanuts. Don't know what any team is thinking here.
Lastly, Chicago is hurting, bad. They moved out a lot of key players and got fairly mediocre returns on them. The Saad trade at least gave them some pieces, but what they got for Sharp was pretty poor. Even after a bad year, Sharp has a lot of upside and has won three Cups for a reason.
Lastly, Chicago is hurting, bad. They moved out a lot of key players and got fairly mediocre returns on them. The Saad trade at least gave them some pieces, but what they got for Sharp was pretty poor. Even after a bad year, Sharp has a lot of upside and has won three Cups for a reason.
Free Agent Frenzy
Toronto finally did well here, signing decent players for cheap to fill out their line-up. They'll still be terrible this season, but are at least setting themselves up to be less terrible in the future.
Montreal did poorly, signing yet another defenseman for too much money without really addressing their inadequate forward lines. Now they're cap constrained for absolutely now reason. Petry's not bad, just not worth that much money and not what they needed.
Colorado, Buffalo and Boston all overpaid for what look to be serviceable but mediocre forwards. They'll pay for it in the future.
Still a few worthwhile free agents out there, especially D-men who are sorely needed by most teams (Nashville & Calgary being the major exceptions).
How the Field Changes Next Year
It's obviously too soon to make any real predictions about how the NHL picture is going to look this coming year, but I'm going to do it anyway!
In the West, Dallas looks good to make the playoffs, likely in place of Vancouver, Calgary, or Winnipeg. LA should challenge as well, but they've got some deeper issues that have yet to be resolved.
In the East, Florida and Columbus may challenge, but Ottawa's the only real weak team I see for them to bump off.
Anyway, should be a good season!
Still a few worthwhile free agents out there, especially D-men who are sorely needed by most teams (Nashville & Calgary being the major exceptions).
How the Field Changes Next Year
It's obviously too soon to make any real predictions about how the NHL picture is going to look this coming year, but I'm going to do it anyway!
In the West, Dallas looks good to make the playoffs, likely in place of Vancouver, Calgary, or Winnipeg. LA should challenge as well, but they've got some deeper issues that have yet to be resolved.
In the East, Florida and Columbus may challenge, but Ottawa's the only real weak team I see for them to bump off.
Anyway, should be a good season!
Saturday 11 July 2015
CanMEDS Competencies and Being a Manager
The CanMEDS competencies are a set of roles of current and aspiring physicians considered integral to being a capable doctor. While they are typically groan-inducing if mentioned to a group of physicians or med students after they get over that "OMG I'm in Med School" feel (typically takes 2 months), they do serve as a reasonably useful framework.
The reason I find them useful is that deficiencies in any one of them by a physician tends to lead to problems for patients, though not always in obvious, easily identifiable ways. As such, they're qualities every well-rounded physician should be working on improving and maintaining.
Yet every single physician has a weakness in at least one of those roles (full disclosure - for me, I believe it's "Collaborator" and to a lesser extent, "Health Advocate"). That's not a terrible thing - we all have strengths and weaknesses, interests and areas where we struggle. Being less-than-stellar in these areas does lead to sub-optimal care, but doctors are humans and no human is perfect, so a degree of sub-optimal care is unavoidable. More importantly, there's a bit of a diminishing return on improving in many of these roles. Being merely competent at all roles gets a physician most of the way to providing good-quality care.
Where trouble can arise is when physicians are exceptionally strong in one area and almost completely deficient in another. The stereotypical example is the physician who is a strong Medical Expert and Scholar, but a horrible Communicator - I can think of several physicians off the top of my head that fit that description. Being great in one role doesn't compensate for being inadequate in another, because physicians have to jump between these roles frequently.
Another point of trouble is when physicians as a group collectively struggle in any one role. Medicine is ultimately a team sport, so mild deficiencies from an individual perspective can be overcome by strength from a group perspective. The "Scholar" role fits that description well - there are certainly many physicians who are not the strongest Scholars, but because the medical field places such an emphasis on scholarly work, the profession overall does pretty well on that front.
There are certainly some of the CanMEDS roles where physicians, as a group, are lacking. We do well on the "Medical Expert" side of things and, as I said, are pretty good from the "Scholar" perspective. Everything else is a bit of a mixed bag. I'd like to briefly focus on one role that I find often gets neglected: "Manager".
When thinking about management, a lot of physicians immediately think of the administrative tasks that we all hate to do, or the administrators whose primary function sometimes seems to be making practicing medicine more difficult. (As an aside, those administrative tasks and administrators are often quite necessary or helpful, but often in a long-term, big-picture way that's hard to appreciate day-to-day). Yet management, at a fundamental level, really just involves organizing groups of people (including yourself) to accomplish a task efficiently and effectively. Physicians do this all the time, whether it's managing other physicians or members of a larger healthcare team. Knowing how to do this effectively is critical to coordinating care.
The basics of this are not that difficult - for the most part, as long as every member of the team knows what they're supposed to do, by when, and who to check in with when it's completed. Yet, it's amazing how often this basic structure does not get followed and how easily teamwork on a project - or a patient - falls apart without it.
Being a good manager also involves knowing how to be managed. Physicians are no longer the automatic leader of any group, for good reason. Being a good team-member is vital to being a good leader. By following, you learn how certain leadership strategies work and how some of them fail, where they can be adapted or improved upon. Following is a skill that physicians don't work enough on and as a consequence, we could be a lot better at the Manager role.
The reason I find them useful is that deficiencies in any one of them by a physician tends to lead to problems for patients, though not always in obvious, easily identifiable ways. As such, they're qualities every well-rounded physician should be working on improving and maintaining.
Yet every single physician has a weakness in at least one of those roles (full disclosure - for me, I believe it's "Collaborator" and to a lesser extent, "Health Advocate"). That's not a terrible thing - we all have strengths and weaknesses, interests and areas where we struggle. Being less-than-stellar in these areas does lead to sub-optimal care, but doctors are humans and no human is perfect, so a degree of sub-optimal care is unavoidable. More importantly, there's a bit of a diminishing return on improving in many of these roles. Being merely competent at all roles gets a physician most of the way to providing good-quality care.
Where trouble can arise is when physicians are exceptionally strong in one area and almost completely deficient in another. The stereotypical example is the physician who is a strong Medical Expert and Scholar, but a horrible Communicator - I can think of several physicians off the top of my head that fit that description. Being great in one role doesn't compensate for being inadequate in another, because physicians have to jump between these roles frequently.
Another point of trouble is when physicians as a group collectively struggle in any one role. Medicine is ultimately a team sport, so mild deficiencies from an individual perspective can be overcome by strength from a group perspective. The "Scholar" role fits that description well - there are certainly many physicians who are not the strongest Scholars, but because the medical field places such an emphasis on scholarly work, the profession overall does pretty well on that front.
There are certainly some of the CanMEDS roles where physicians, as a group, are lacking. We do well on the "Medical Expert" side of things and, as I said, are pretty good from the "Scholar" perspective. Everything else is a bit of a mixed bag. I'd like to briefly focus on one role that I find often gets neglected: "Manager".
When thinking about management, a lot of physicians immediately think of the administrative tasks that we all hate to do, or the administrators whose primary function sometimes seems to be making practicing medicine more difficult. (As an aside, those administrative tasks and administrators are often quite necessary or helpful, but often in a long-term, big-picture way that's hard to appreciate day-to-day). Yet management, at a fundamental level, really just involves organizing groups of people (including yourself) to accomplish a task efficiently and effectively. Physicians do this all the time, whether it's managing other physicians or members of a larger healthcare team. Knowing how to do this effectively is critical to coordinating care.
The basics of this are not that difficult - for the most part, as long as every member of the team knows what they're supposed to do, by when, and who to check in with when it's completed. Yet, it's amazing how often this basic structure does not get followed and how easily teamwork on a project - or a patient - falls apart without it.
Being a good manager also involves knowing how to be managed. Physicians are no longer the automatic leader of any group, for good reason. Being a good team-member is vital to being a good leader. By following, you learn how certain leadership strategies work and how some of them fail, where they can be adapted or improved upon. Following is a skill that physicians don't work enough on and as a consequence, we could be a lot better at the Manager role.
Thursday 9 July 2015
A Wild Clerk Appears!
I found out a few days ago that I had passed my final pre-clerkship exams. I can't say enough how excited I am about being officially done with my pre-clerkship education and to be moving onto the clinical portion of my schooling.
Unlike most medical students, I did two undergraduate degrees before applying to become a physician. My first was very theoretical in nature and at best tangentially related to medicine. It was never meant to lead to medical school - my goal coming out of high school was to go onto do a PhD in that field and to work as a researcher. I was capable in this field - better than many, but hardly near the top of my undergrad class. I was also rather unmotivated to push forward. Academia is supposed to be about a greater purpose - expanding humankind's understanding of the universe - but the major impact of doing a good job is personal career advancement (see this comic, courtesy of PHD Comics, which you should definitely be reading if you're considering graduate work either outside of a medical career or in one). For whatever reason, I never found enough of an intrinsic passion for my work in that field and could never push past that apathy to do work that was largely for my own benefit.
Anyway, later on in my first undergrad, I started doing some volunteer work, mostly with kids. I honestly forget why - I hadn't done much volunteer work in high school and it wasn't in any way related to field. But, I enjoyed it, enough so that it became the highlight of my week.
That led me towards healthcare. After doing a quick volunteer stint at the local hospital, I ended up doing a second degree which led to certification as an Allied Health Professional (I won't say which one to preserve a small shred of anonymity). I loved it. Virtually everything was directly applicable to an actual job - even the academic work had practical relevance in the short-term. I found it much easier to work on projects, knowing they might have some tangible benefit to others, and studying wasn't nearly as difficult. The clinical component, as hard as it was, was incredibly rewarding - working with patients made learning the rest easier, in part because I had a lot of internal motivation to do things right for those patients.
Going to med school has felt like a short repeat of those two programs. My pre-clerkship years have felt a lot like my first undergrad. While the material is ostensibly practical in medical school, there is no expectation of mastery of material in pre-clerkship like there was in my second undergrad and the direct relevance to practice is frequently unclear (this was particularly true for a few specific subjects). As a few physicians opined, doing well in pre-clerkship is pretty meaningless to a student's likelihood to do well in practice.
Because of this, I've struggled a bit through my pre-clerkship days. Don't get me wrong, I've passed everything without too much difficulty (though maybe a bit of finger-crossing) and have managed to put together a set of extra-curriculars (including research) that I hope will reflect well on my ability to be productive, but it has not been easy to push myself to perform. I certainly could have done better in my classes than I did.
My hope is that clerkship will be a bit more like my second undergrad - more applied, more meaningful human interactions.
Long story short, I'm looking forward to the next year.
Unlike most medical students, I did two undergraduate degrees before applying to become a physician. My first was very theoretical in nature and at best tangentially related to medicine. It was never meant to lead to medical school - my goal coming out of high school was to go onto do a PhD in that field and to work as a researcher. I was capable in this field - better than many, but hardly near the top of my undergrad class. I was also rather unmotivated to push forward. Academia is supposed to be about a greater purpose - expanding humankind's understanding of the universe - but the major impact of doing a good job is personal career advancement (see this comic, courtesy of PHD Comics, which you should definitely be reading if you're considering graduate work either outside of a medical career or in one). For whatever reason, I never found enough of an intrinsic passion for my work in that field and could never push past that apathy to do work that was largely for my own benefit.
Anyway, later on in my first undergrad, I started doing some volunteer work, mostly with kids. I honestly forget why - I hadn't done much volunteer work in high school and it wasn't in any way related to field. But, I enjoyed it, enough so that it became the highlight of my week.
That led me towards healthcare. After doing a quick volunteer stint at the local hospital, I ended up doing a second degree which led to certification as an Allied Health Professional (I won't say which one to preserve a small shred of anonymity). I loved it. Virtually everything was directly applicable to an actual job - even the academic work had practical relevance in the short-term. I found it much easier to work on projects, knowing they might have some tangible benefit to others, and studying wasn't nearly as difficult. The clinical component, as hard as it was, was incredibly rewarding - working with patients made learning the rest easier, in part because I had a lot of internal motivation to do things right for those patients.
Going to med school has felt like a short repeat of those two programs. My pre-clerkship years have felt a lot like my first undergrad. While the material is ostensibly practical in medical school, there is no expectation of mastery of material in pre-clerkship like there was in my second undergrad and the direct relevance to practice is frequently unclear (this was particularly true for a few specific subjects). As a few physicians opined, doing well in pre-clerkship is pretty meaningless to a student's likelihood to do well in practice.
Because of this, I've struggled a bit through my pre-clerkship days. Don't get me wrong, I've passed everything without too much difficulty (though maybe a bit of finger-crossing) and have managed to put together a set of extra-curriculars (including research) that I hope will reflect well on my ability to be productive, but it has not been easy to push myself to perform. I certainly could have done better in my classes than I did.
My hope is that clerkship will be a bit more like my second undergrad - more applied, more meaningful human interactions.
Long story short, I'm looking forward to the next year.
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