Sunday 30 August 2015

Got My Hospital ID

So, I got my ID for Clerkship on Friday. Very excited to have one of these again, makes me feel less like an impostor when I'm at the hospital, which will now be a full-time thing in less than a week.

Still have a surprising amount to do in a very short time to get ready for Clerkship. They really don't mess around with the required tasks this year.

Also, scary topic of coversation from today - starting work at 6 am. Scarier topic - starting at 5:30 am if I want to be thought of as truly hard-working. I get up and going well before most of my classmates, but that still means waking up at 5:30, not being dressed and everything by then! I have a feeling sleep will be a luxury at times this year...

Saturday 29 August 2015

Follow-Up on Physicians Doing Good

The last post painted a somewhat depressing picture, indicating that while physicians certainly provide some benefit to their patients, the average physician's direct impact on their patients is not all that high, or at least not as high as we'd sometimes like to think.

But it's not all bad news - as mentioned, there are plenty of ways physicians can beat the average, either by improving their direct impact on their patients or by having an impact outside the clinical setting. Here's some approaches I'm trying to keep in mind as I move through my training.

1) Do a Good Job

I'm in Medical School because, presumably, I was a better candidate than the person who would have gotten in if I had never applied. However, since medical school admissions is an imperfect process, there's no guarantee I'll be a better physician than the person who would have replaced me. If nothing else, my job is to do my absolute best to be an improvement over my hypothetical replacement.

That means reading as much as possible in a way that it'll stick in my head long enough to be of value. That means developing physical skills I'll use in my career in a way that leads to mastery. It means keeping on top of new developments, new studies, new innovations that have the potential to improve care meaningfully. It means understanding some of the wider contributions of society on health and incorporating that knowledge into practice.

It's pretty cliché, but being good at what you do for a living can make a considerable difference.

2) Pick a Meaningful Career Path

As mentioned multiple times on this blog, I'm a bit obsessive over what my specialty choice will be. Every physician (hopefully) does some good for their patients, but exactly what kind of effect they have on the patients they serve can vary wildly. The previous post talked about the average effect on QALYs physicians have, but not every physician has the same effect on their patients' QALYs. Some physicians improve or prevent disability, working more on the "QA" side of QALYs. Some spend more time on extending life, improving the "LY" side of QALYs.

There's undoubtedly some variation in the overall impact on QALYs each physician has as well; some physicians' daily work probably saves or improves more lives than others, though I can only guess which specialties and practice types have more or less of an impact. Given trends in global health, I'd argue physicians who care for pregnant women, young children, or those who focus on infectious disease are probably contributing more than their fair share to overall QALY improvements. Likewise those who work in specialties that need more physicians, such as geriatrics, or in underserved areas, are providing a high marginal value of care since their work is often in place of nothing (rather than in place of another physician).

Ultimately, a physician should enjoy the work they do - it certainly helps with point #1 - but it's worth considering the net effect on patients when choosing a path. All physicians feel like they're doing good, but the point of the 80000 hours site is that feeling good isn't enough. It's something I'm keeping in mind when choosing a specialty.

3) Donate Some Money

Doctors as a whole suck at money management. The typical physician goes from being a student with no money (and potentially a lot of debt) to being a resident with some money (but a lot of debt to pay off) to a practicing physician with lots of money. There's not much time for proper budgeting to be learned - either there's not enough income to budget with anyway, or there's so much income that budgeting feels unnecessary.

This leads to a concerning number of physicians with money problems, because their high incomes get cancelled out by equally high (and often unnecessary) expenses. That can lead to some bad consequences for the physicians themselves, but it also cuts off a major way in which physicians can help others - donating to charity.

The impact of charitable donations depends heavily on the organization or cause being donated to. Evidence-based charities can be very effective, especially in lower-GDP countries where there are a lot of identifiable problems to address. A physician living conservatively with strong money management can easily donate 10%, 15%, or even 20+% of their income to worthy charities while still enjoying life and saving for retirement. Over a career, that's hundreds of thousands of dollars going to improve others' lives. That can make a much greater difference than even the most dedicated clinician can contribute directly.

4) Work Outside the Clinic

Physicians have surprisingly good career flexibility. They can do research and/or development. They can be advocates for better health. They can teach the next generation of physicians (and sometimes non-physicians). They can transition from being a physician to other careers in business or politics. This can provide a lot of indirect benefit to people both through healthcare and outside of it.

There's lots of options, so it's worth figuring out which ones are best for each individual physician or physician-to-be. I'm focusing pretty heavily on the research side of things right now, though it's mostly just career development at this stage. My advocacy is largely limited to my online postings, which are probably of minimal value given that my audience is fairly small (but highly valued!) and I'm probably preaching to the choir more than anything else. I am putting in a fair effort on the education front, through organizing teaching sessions, some educational research, and even direct teaching myself.

How these evolve as I move forward in my education and then in my career as a physician is pretty uncertain at the moment, but I want to push ahead in at least some of these areas, if not all of them. Not only do they provide some variety in my day-to-day activities, but they could be as meaningful as my direct patient contact, if I pursue them with some wider goals in mind.

Anyway, I wanted to present this as a counter-point to the previous post. Being a physician isn't automatically as beneficial to the world as we sometimes like to believe - but the potential to do a lot of good is still there, even if it takes some work, some discipline, and some thinking outside the box to make it happen.

Wednesday 19 August 2015

Want to Help Patients As a Doctor? Donate to Charity

Students want to become doctors to help people. But how good are physicians at doing this?

I stumbled across a site on having a productive career that helps others. It has some interesting insights, but I'm particularly liking their analysis of the effects of being a physician. Physicians treat patients and presumably do a good job of it, but the overall effect physicians have on health is likely not that substantial for most patients. More importantly, physicians don't see that many patients in the grand scheme of things (though at times it certainly seems like they're seeing too many).

In medicine, a common, standardized way to evaluate how effective or how cost-effective an intervention is involved the use of Quality-Adjusted Life-Years (QALYs). I've always wanted to get an estimate of how many QALYs can be attributed to a typical physician, and the folks on this site have done a pretty good job, putting it at a maximum of around 2600 QALYs over a career. They further adjust for the marginal effect of any particular person choosing to become a physician - after all, there are diminishing returns for adding additional physicians, and if I wasn't in medical school, someone else would be. Presumably, I'm a better candidate than the person who would have replaced me, but I doubt the difference would be that substantial. They put the marginal effect of a typical person choosing to pursue medicine (and then doing so) at around 600 QALYs.

And even these numbers attribute the entire benefit of medicine to physicians, which is hardly the case. The estimates drop pretty quickly as you reduce the proportion of credit given to physicians. Anyway, it's worth checking out the analysis in full. There's a bit of room to quibble, but most of that pushes the estimates down - 2600 additional QALYs attributable to an average physician looks to be like a pretty reliable high-end estimate.

Now, saving 2600 years of life or providing the equivalent increase in quality of life is still pretty impressive, particularly in the developed world where the low-hanging fruit of improving people's lives (especially reducing poverty) has either been addressed already or is surprisingly difficult to make further strides against. Not all physicians have the same impact - higher quality physicians presumably have a greater impact and there are undoubtedly differences based on the specialty chosen and the nature of a physician's practice.

Yet, perhaps the greatest way physicians can help others is by donating to effective charities. Physicians earn a lot of money and do so rather reliably. A physician's charitable donations, if done efficiently, can provide benefits to humanity that dwarf what they provide in direct benefit to their patients, according to these authors' analyses.

There are additional avenues through which physicians can improve lives. Research and development can lead to broad improvements in quality of life across the world, well beyond what a physician can accomplish directly. However, not all research is successful in developing improvements for healthcare or overall health, and the real-world effects can often be modest. Advocacy is another avenue for improvement of overall well-being, but the average physician isn't that influential. There are ways to increase that influence though, such as formal or informal writing, or by working with advocacy groups for specific causes. Teaching can be another way to contribute, as knowledge translation is important to preserving current improvements in QALYs due to modern medicine and a strong teacher-physician may be able to improve the quality of the physicians they instruct.

So do doctors help people? Yes, but the direct impact isn't as high as many people think and there are other pathways that could have a much larger impact on humanity as a whole. Being a doctor is as much about feeling like you're doing good than it is actually doing good. That's not a criticism. It's important for us to enjoy our careers and feel valued at them - our quality of life matters too! Still, we should be aware of our own limitations and those of our profession. Physicians do good work. When I become one, I hope to do good work too, work that will hopefully help people. But the work we do isn't uniquely good and there are many ways we can have a meaningful impact on others' lives outside of our clinical practices.

Saturday 15 August 2015

Update on Ministry Reduction of Residency Positions

A while back, word came out that the Ontario government was cutting funding for 50 residency positions in Ontario designated for Canadian Medical Graduates in the first round of CaRMS. Details were sparse, because many of them were apparently still up in the air with discussions still underway. There was a lot of back-channel information coming out, but all of it hard to verify. Even the announcement itself came from student organizations - a reliable source, but not the ones making these decisions, so there was no guarantee even the information from them was representative of the final policy.

My school recently sent out a memo with a few additional details. It's still not from the Ministry, so the information is potentially subject to change, but it's as reliable as could be possibly expected at this stage. Two main pieces of information came out of that memo.

1) Rather than 50 CMG positions cut over the next two years, it will be 25 CMG positions in 2016 then 25 IMG positions in the 2017.
2) While the specialties losing positions are still undecided, the cuts will be proportionally split across all Ontario schools, meaning schools with large residency programs (like U of T) will lose more spots than schools with small residency programs.

The change from 50 CMG positions to 25 CMG & 25 IMG positions is fairly significant. The main difference is that we get to keep a slight buffer of excess CMG positions relative to graduating students, with about 3% more positions than students. That's important to maintain because while most CMGs match to a residency the year they graduate, a few do not. Those excess spots provide some flexibility for those previous years' graduates to find a residency, which most do. Indeed, of the cohort that graduated in 2013, all but about 10 people have found a residency, which is how the system is intended to work.

When a CMG fails to match, it means their education - which is heavily taxpayer subsidized - goes to waste. If these CMGs are truly unfit to practice, that would be an acceptable loss, but there's little indication that's the case for most CMGs who don't match their first year. As an aside, CMGs who are not residency-worthy probably shouldn't be getting their MD in the first place, but completely failing out of medical school in Canada is a relatively rare. Cutting 50 CMG spots would have effectively eliminated the buffer. Without that buffer, the number of people permanently failing to find a residency would almost certainly have grown from the current ~10 per year, adding unnecessary waste - waste of both dollars and people - to our medical education system. With a smaller buffer, the number of CMGs failing to match in the first round of CaRMS the year they graduate will go up and the number who fail to match in their graduating year after the second round will probably rise, but the number of people who never find a residency shouldn't jump by much, if at all.

It's still not my preferred approach to cutting 50 residency positions - I'd rather see all 50 positions cut be IMG spots - but it's an improvement.

Here's the thing - because unfilled CMG spots open up to everyone in the second round, IMGs ate up whatever excesses were built into the system for CMGs. Cutting IMG spots therefore becomes a more efficient and direct means to achieve the same ends. The sense I get is that the Ontario government was worried about the optics of cutting only IMG spots and so split things between CMG and IMG positions.

More cynically, I'm worried the Ministry representatives making these decisions may not fully understand the effects of these cuts and are making changes on the fly. What little information that has come out about the Ministry's goals or intentions when making these cuts doesn't always square with the impact of their decision. I also trust the CFMS and OMSA. Perhaps they were mistaken in their initial report that all 50 positions cut would be CMG spots, but I'm inclined to believe that was the Ministry's original intention. There are fewer IMG positions which mostly exist in larger programs, so it'd be easier to cut 25 IMG spots on short notice than 25 CMG spots. Fewer programs to coordinate with and evaluated. Yet the CMG spots are getting cut first. It's pure speculation, I will fully admit, but I suspect the Ministry decided to switch the cuts in 2017 from CMG spots to IMG spots after the CFMS/OMSA statement.

In any case, the full impact of these cuts won't be known until all the details are out, which are at least a month away. With any luck, the positions lost will be in specialties with low patient demand and/or mediocre job markets. We'll know soon enough.

Thursday 13 August 2015

Who You Work With

I'm having a busy end to my summer. I've had half a dozen projects on the go and right now four group efforts are all demanding quite a bit of attention. I somehow signed myself up for things that are all either due at the end of the summer or have responsibilities that need to be addressed at the start of the school year, so it's all coming together in one giant mess of craziness and mild panic.

Yesterday was a great representation of that. I started the day at around 8:30 am, not including morning e-mails or other communications that I often read/send when eating breakfast. I ended the day around 8:30 pm, not including reading/sending evening e-mails. I wasn't exactly hard at work that whole time - I was able to get home for some of the afternoon to have lunch, walk the dog, etc. Still, it was a long day.

Yet, it was also a very good day, and I have the people I work for and/or with to thank for that. We managed to push forward several of the projects I have on the go yesterday, one in a very meaningful way.

Working with committed, enthusiastic, and understanding people makes every project so much easier. Tasks get done quickly, competently and reliably. Coordination is easy. Joint tasks and meetings feel less like work and more like regular socializing. I've spent hours in meetings over the past few weeks and genuinely enjoyed my time.

I like to think I'm a generally productive student and I'm proud of what I've been able to contribute to my school and to my community. However, this week has been a great reminder of all the guidance and support I've had with my initiatives so far. Any successes I've had have come from the hard work of my mentors, my collaborators, and my colleagues. I have been extremely fortunate to have good people to work with.

Wednesday 12 August 2015

Get Some Exercise!

I put on a good 20 lbs this year, mostly due to declining activity and a worsening diet. I've started (slowly) reversing that trend, getting a bit more exercise and definitely eating better, but to keep that going, here's friendly reminder (mostly to myself) that exercise is really good for you!


Healthcare Triage. It's awesome. You should watch it.


Research on lifestyle and its effect on health is often fairly tricky. Nutrition research in particular is fraught with challenges that make a simple interpretation of available evidence very difficult. But exercise has some fairly clear-cut and wide-ranging benefits, for both physical and mental health.

Something the video (and available literature) don't support is the notion that basic exercise causes weight loss - though more extreme body-sculpting regimes may be better on that front. So, while I'm increasing my activity in part because of an increasing waistline, my dietary changes are likely to matter more on that front. The flip side is that even when exercise doesn't lead to weight loss, it still leads to better health. So get some exercise!

Sunday 9 August 2015

If I Don't Study Medicine Abroad, What Are My Options?

As I said in a previous post, studying medicine abroad is a risky proposition - it's quite expensive and has a rather high chance of failure. Yet, students often pursue that route because they feel like there's no other option to becoming a physician - they can't get into a Canadian medical school, so that's the next best thing. However, there are alternatives! Here they are, with some pros and cons to each, in no particular order:

Doctor of Osteopathy (DO) Programs in the United States

Pros: DOs are essentially equivalent to MDs in the US. Their training is essentially the same as it is for MDs, with a bit of a higher focus on primary care and a holistic approach to patient care. They have their own residency programs in the US - which they can fairly easily match into - and they're now eligible for MD residency programs in the US as well. Getting into a DO program is easier than pretty much any Canadian MD school. There are a few DO programs specifically interested in Canadian students.

Cons: Their programs are expensive for Canadians and any loans would require a cosigner. While DO programs have lower entrance requirements than Canadian MD programs, they still have standards and a reasonably competitive application process, so they're not an option for everyone. Obtaining a residency in Canada is subject to some odd province-to-province inconsistencies and generally not much easier than it is for CSAs and some programs are completely off the table. The main difference between DO and MD programs is training in osteopathic manipulative medicine (OMM), which is widely regarded as ineffective by non-DOs (and by more than a few DOs as well). Due to OMM and lower entrance standards, there is still a bit of a stigma against DOs in the US and Canada. DOs will be subject to the new J1 visa restrictions in the US, meaning opportunities to do residency in the US may be somewhat more challenging.

Summary: The DO route for Canadian students is, in many ways, like CSA-light. It shares many of the upfront costs in terms of money and moving to another country, and the chances of doing a residency in Canada aren't much better than the CSA pathway. However, with virtually no difficulties getting a US residency position, the chances of outright failure are low. The incoming visa restrictions complicate this somewhat, but there is always the option to go for an H1-B visa (one sponsored by the residency program rather than by Canada, as is the case with J1 visas), which is much more plausible as a US DO graduate than as an IMG without any connection to the US. A decent fit for some people, but proceed with caution and be realistic about likely outcomes.


MD Programs in the United States

Pros: About as close as you can get to going to a Canadian medical school without actually attending one! USMD programs are accredited by the same organization Canadian schools are, and USMD graduates are considered identical to Canadian grads when it comes to the CaRMS match. High-quality training is guaranteed, the chances of coming back to Canada to do residency are relatively good, and there is ample opportunity to do residency in the US.

Cons: Still quite expensive to attend and still requires a move away from home. If a residency in the US is pursued, all those new visa issues will still apply, though USMDs are in the best position to get an H1-B visa. Entrance requirements are different than most Canadian medical schools, but still at about the same level - there aren't that many people who have no shot at Canadian schools but could easily secure a US MD position.

Summary: If you can finance a US MD and are willing to live at least 4 years outside of Canada, this is the best option, by far. High chance of a good outcome, with low chance of true failure. There are some regulatory complexities that are worth being aware of and Canadians in US MD programs probably have to work a bit harder to keep themselves competitive than Canadian MDs do, but the outlook for both is about the same.


Improve Your Application to Canadian Medical Schools

Pros: No one is ever, 100% out of the running for Canadian medical school admissions. Low GPAs can be overcome with short (2-3 year) second undergrads, or in some cases, a single extra year. Grad school is also an option for some applicants. The MCAT can be rewritten. ECs can be improved. You can add knowledge, skills, and contacts that can be of use in your career as a physician, should you get into a Canadian school. You can (and should) develop an alternative career while simultaneously improving your medical school application. Done right, this pathway takes nothing off the table in terms of your future career prospects and might open up some new ones. You can also stay in Canada.

Cons: Time. Money (though not nearly as much as the other options). It can feel like you're moving sideways rather than forward, even when you are moving forward. To get into a Canadian school, you'll have to do well at something that you previously weren't that great at, so there is a real possibility you won't succeed in becoming a physician.

Summary: This is the humble option. It requires admitting that you might not be ready for medical school - yet. It's the pathway with arguably the highest upside - being a physician in Canada without ever having to leave the country. The downside at first seems pretty bad - if you don't get into a Canadian school, you don't get to be a physician - but unlike the CSA path (and to a lesser extent, the DO and USMD paths), if it doesn't work out the consequences are fairly minor. You won't have nearly as much crippling debt to deal with. An alternative career should already be in development if you don't get into medicine, which makes it easy to go onto other pursuits - CSAs can't easily develop a back-up career in case they don't get a residency.

Everyone, and I mean everyone, has more than one career that would make them happy - even if medicine is your calling, you probably have dozens of other callings! While going the CSA route is risky, this option is safe, but it requires some patience and humility. There are worse traits for aspiring physicians to have in abundance.


Conclusion
To wrap things up, I generally advise people not to study medicine abroad, because I find any of the three options listed above to be preferable. I don't see any reason to pursue medicine outside of Canada or the US if either DO schools or USMD schools are possibilities. Choosing to improve one's chances at Canadian schools instead of studying medicine abroad is a bit more of a judgment call. I see the risk of studying abroad as unacceptably high, while the possibility of pursuing a career outside of medicine is, to me, perfectly acceptable (even though I'm quite happy with the path that I'm on). Those with a different tolerance for risk or a different definition of what they consider an acceptable career path might disagree and choose the CSA route.

The point is that there are always options and that they should be explored fully before making a final decision. I was at a hotel recently where international medical schools were holding an event to recruit Canadian students. The event was hosted by people who were essentially salesmen. Their goal is to get students' money, not to look out for their best interests. Again, for some people, the CSA route may be the best choice according to their values and personal preferences, but too many go abroad misinformed and wind up disappointed.

Friday 7 August 2015

Jon Stewart

Last night, Jon Stewart hosted his final Daily Show. After 16 years, he's finally decided that he's done and is stepping aside.

Like many people my age, I first started watching the Daily Show when I was in high school, right when I was trying to make sense of the broader world.. I explored religious viewpoints, political viewpoints, philosophical viewpoints, historical viewpoints, all telling me how others' thought the world worked. Turning on the Daily Show, Jon Stewart told me that, in fact, the world didn't work.

More importantly, he explained why it didn't work and occasionally, how it might be changed so it would work, all through a biting form of sarcastic humor that made it all entertaining and accessible - two qualities all other viewpoints I explored seemed to lack. The Daily Show provided a form of cynical optimism about the world.

I found that utterly compelling. Rather than accept that bad things happen in the world because they're inherently that way, Stewart cynically pointed the finger at people - both individuals and groups - to hold them accountable in some small way for their contribution to the poor state of the world. And then he pushed them to change, to be better, because ultimately, it's not about good people vs bad people, but about good ideas, attitudes, and actions vs bad ideas, attitudes, and actions.

I can't say how happy I am that in his final monologue, Stewart talked about Bullshit. Bullshit is everywhere, and we all spew it, though some more than others. Bullshit comes in many different forms and exists for a near-infinite number of reasons. Bullshit takes the truth and dirties it, buries it, disguises it. Bullshit builds because we actively produce it ourselves, because we become complicit when others produce it, and because we become complacent about clearing it out. Yet when we, together, make an honest effort to reduce the harmful Bullshit we collectively produce and to clear out some of the Bullshit already lying around, we can find some real, meaningful answers to the challenges facing this planet. And maybe, just maybe, we can move forward.

This is ostensibly a blog about medicine and healthcare, so I'd be neglectful not to mention all the Bullshit that exists in medicine and as a healthcare practitioner, gets thrown your way on a regular basis. Bullshit comes from colleagues, coworkers, students, administrators, governments, insurers, researchers, families and from patients themselves. However, just as with everything else in life, there are ways through the Bullshit. I see many people in healthcare get beaten down by the crap thrown their way, but I also see many push through it, past it, above it. Those who seem to thrive in medicine despite the endless stream of nonsensical Bullshit are the ones who still have hope that the system can be improved and are actively working to make that a reality. In most cases, simply pointing out that the Bullshit exists makes a huge difference, because change happens when enough people believe it should.

As Stewart closed with: "The best defense against Bullshit is vigilance. So if you smell something, say something". Couldn't have said it any better.

Wednesday 5 August 2015

Should You Study Medicine Abroad?

Medical school in Canada is competitive. Very competitive. As a result, many aspiring physicians look to alternative routes to becoming a doctor that don't involve attending a Canadian medical school. The number of students choosing this route was very small only a decade ago, but has grown substantially, particularly in the last few years. The stated reasons are diverse, but most students study medicine outside of Canada because they are unable or unlikely to obtain admissions to Canadian medical schools.

So I see this question a lot from people interested in pursuing medicine but with an application that is below the standards for Canadian medical schools: should I study medicine abroad?

To answer that question, there are a few considerations worth addressing.

First and foremost is cost. Medical school is expensive. In Canada, our schooling is heavily subsidized and Canadian medical students (CMGs) have access to cheap loans, both private and public. Canadians Studying Abroad (CSAs) get no subsidies, have access to higher-interest private loans that typically require a cosigner, and public loan availability varies by province. Some schools are more expensive than others, but $200k in total costs is about the bottom line once tuition, living expenses, and travel are considered. Some schools require significantly more debt. Australian schools, for example, have very high tuition for international students, in the range of $60-70k per year, leading to total costs reaching $400k.

Second is likelihood of a successful outcome. After all, CMGs also take on a fair bit of debt, with $125-150k being a typical debt load after med school, but it's a worthwhile investment because a CMG's chances of a career in medicine (and the high salary that goes along with it) are very, very high. Virtually guaranteed, in fact. CSAs aren't so fortunate. The chances of matching into a Canadian residency have fallen from an already-scary ~50% to around 30%. As more people decide to study abroad, that number is more likely to fall than it is to rise, barring an increase in IMG-dedicated residency positions.

Now, success doesn't have to mean obtaining a Canadian residency - there is the option for residency positions outside of Canada. However, most countries that train CSAs for medical school have little interest in providing residency positions for them, unless they happen to be a citizen of that country. In many cases, that leaves the US as the only viable option for CSAs unable to obtain a Canadian residency. Non-citizens of the US without a US medical degree already face an uphill battle, but that situation looks to get even worse. Not only is there increased competition for US residency positions, but many of these residency positions can only be obtained by a Canadian if they have a study visa endorsed by Canada. These J1 visas used to be offered in essentially unlimited numbers, but recently, it was announced that hard limits will be placed on these endorsements for would-be physicians wanting to train in the US, limits that are set to shrink each year. Those limits apply collectively to CSAs, Canadians studying at US MD or DO schools, as well as CMGs wanting to do their residency in the US. These endorsements are first-come, first-serve, and without them, even if a CSA obtains a US residency positions, they cannot legally study in the US. If the US was the pressure valve on the build-up of CSAs without a Canadian residency, it appears that may not longer by the case.

All told, CSA opportunities to become a fully-trained physician are mediocre at best and dwindling quickly. Strong performance in medical school can improve one's chances (as does having connections, sadly), but there does seem to be a major luck component.

Despite these odds, some CSAs do successfully complete their training on this pathway and manage to practice medicine in Canada. And, despite an ever-worsening outlook, there will probably still be CSA success stories in the future. The CSA route is a viable path to practicing medicine in Canada, just not a reliable one.

So, should you study medicine abroad? If you have enough money or credit to pay the cost of being a CSA and can accept a large (50%+) chance of failure, then maybe. Otherwise, probably not.

On Publications and Presentations

I'm pretty much neck-deep in research projects right now, so research is on my mind a lot. One thought that popped up, relevant to the previous post, is the nature of research productivity that is valued through a physician's career, especially in the early stages.

The culture in universities is to put a fairly high emphasis on publications. This follows directly from the incentives for professors and other career researchers, where "Publish or Perish" is very much a reality - maybe not so much on the "Perish" side, but the incentive to publish to secure grants and provide for career advancement absolutely exists. This mentality rubs off on pre-medical students, who often believe that research is worthwhile if and only if it leads to a publication.

Yet when it comes to medical school applications in Canada, having a publication is not that important. A few schools don't even look at publications. For those schools that do consider research output, while a publication may be a nice bonus to an application, it's the research experience itself. The premium of having a publication over a conference presentation appears to be rather minimal, even at research-focused schools such as U of T.

In medical school and residency, this attitude towards publications and presentations largely continues - while publications are preferred, presentations are often completely acceptable. There are some exceptions, of course, where residencies expect publications during med school to match to their programs and/or during their residency program itself, but these seem to be the minority. This state of affairs makes absolute sense to me, and helps mitigate challenge of encouraging research experience from future physicians when many have no interest in being career researchers.

The trouble with publications as a tool for evaluating a candidate in medicine is that they're really not suited to determine research aptitude at the early stages of a career. For the most part, pre-meds, med students and residents do not run their own research projects. Rather, they join an existing project or start one under the direction a supervisor. This puts much of the power to produce a publishable manuscript out of the hands of those trainees. The type of project, when the trainee joins the project, and the preferences of their supervisor typically dominate any efforts on the part of the trainee to push the project forward. This effectively means that whether a trainee gets a publication from a research project is largely up to chance. Even when a publication comes, how that reflects on the abilities of the trainee can be highly variable.

Presentations avoid a lot of those limitations. They are relatively easy to get, provided a student or resident has put some effort into a research project. They're not held to the same standards as publications, don't necessarily require a fully-completed study, and there are ample opportunities for presentation in virtually all fields. There is a bit of stratification of quality - some conferences are more prestigious/competitive than others, oral presentations are generally considered more meaningful than poster presentations - but that stratification is not nearly as significant or formalized as journal publications. Basically, a presentation is a presentation.

All else being equal, a publication is harder to obtain than a presentation, and for anyone considering a long-term career in research, it's worth pushing for the publication. For those just looking to advance along the pathway to being a physician, a publication often works just fine. In terms of balancing the need to evaluate trainees for their research chops without unduly punishing those who hate research or are simply unlucky, asking for presentations is a much more reasonable standard than insisting on full publications.

Sunday 2 August 2015

The Value of Research (or lack thereof)

Okay, misleading title, of course research is important! It's how we figure out what things are true and what things aren't!

Yet for people on the spectrum of training to become a physician, the value of participating in research in terms of the potential benefit to their careers is real and, at times, troubling issue.

Medicine is undeniably linked with research. It is a rapidly evolving discipline, which draws on knowledge from virtually every field of research to develop, design, discover, and test new, presumably better ways of keeping people healthy. Understanding research is essential to the good practice of medicine and medicine doesn't improve without good-quality research. Physicians in particular have a large role in this - physicians often conduct their own research or enable research activities as part of a larger group. They can also stifle research performed by others. In clinical research, the most valuable resource is access to patients and their medical information. Obtaining access to these patients often goes through physicians, or at least involves their consent and cooperation. Without an interest in or support of research, physicians can deny or significantly hamper clinical research initiatives.

As a result, research is often considered valuable in terms of improving a person's CV at virtually every stage of training. Research helps undergrads become medical students (though not at all schools and probably not as much as some pre-meds think). Research helps medical students obtain their desired residency positions. Research helps residents get their desired fellowships and/or their desired employment. Even after employment, research productivity can enhance their career prospects.

Yet being a good physician doesn't necessarily require being a good researcher, or even a mediocre one. It is entirely possible to be able to understand emerging research without producing your own. Furthermore, while physicians resistant to research can hamper its progress, physicians do not need to lead or even be active participants in the research process to be supportive of research involving the patients they see.

And to be clear, some physicians and physicians-to-be hate conducting research. However, because it is so highly valued at each stage in the process of becoming a physician, including working in medicine, many people feel compelled to engage in the research process even if they would generally prefer not to. It's a hoop they have to jump through, nothing more.

So, should physician careers hinge as much as they do on research output? Should research output matter at all? Are we creating a perverse incentive scheme by placing a value on research throughout the career checkpoints of medicine?

There are certainly people at all stages of training and practice who would argue we shouldn't put any emphasis on research productivity in medicine, or at least clearly separate research achievements from progress in clinical ability. There are others who argue that physician disinterest or inability in a research sense is holding back the progress of medicine, to the detriment of the patients these physicians treat.

For my part, I engage in quite a bit of research and will likely continue to do so for most of my career. But I do this because I enjoy participating in research! I learn a lot from my time doing research and I'm willing to go to some extremes to be a more active researcher. I had my last set of pre-clerkship exams a few months ago, with four exams in five days - Monday, Tuesday, Thursday, and Friday. On the Wednesday of that week I presented some of my research at an international conference. Spent hundreds of dollars in conference fees (it was a week-long conference), 8 hours in a car, and lost the one day I had to relax/study during my exam week for 15 stress-inducing minutes on a stage in front of people much smarter than I am. Totally worth it. It'll look good on my CV, don't get me wrong (competition for an oral presentation is fairly high at this conference, I'm told), but I could have had a colleague do the presentation and it still would have looked good on my CV. I just really enjoyed the experience, even though it was not my first (nor, I hope my last) time presenting my research in such a manner.

So I'm torn on this issue. I've seen first hand the value of research, both to society at large and to the competencies of individual physicians-to-be. I've also seen how hard it can be for intelligent, interested, and even experienced researchers to be productive in their field without physician support. However, I've also seen first hand how the insistence on research can frustrate and depress physicians or physicians-in-training who would rather focus on doing the best they can for the patients in front of them, which is, ultimately, their primary duty. I don't have a good answer of how to reconcile these observations.

Any thoughts from the audience?