Research in Medical Education

I'm a medical education buff. I'm a true believer that to get the best healthcare system you need the best physicians and to get the best physicians you need to get the best students and train them well.

Today I attended and presented at a conference on medical education. It was a relatively small, local conference, but I can't say how excited I am by the work being done in the field of medical education and what's already been accomplished. The keynote speaker was particularly engaging, delivery an evidence-based, rather sensible and jargon-free presentation. Research in the social sciences - including education - tends to get bogged down with buzzwords that don't add much to clarify the concepts but really hamper knowledge transmission and transmission into practice.

Anyway, here were my big take-aways:

First, the Netherlands apparently has adopted the CanMeds framework (AMAZING!). In addition, they seem to have done a much better job at translating it into a workable approach to medical education (wait, WHAT?!). That's right, the Netherlands seems to actually implement the CanMeds competencies into training rather than simply talking about them, which is what happens most often in Canadian medical schools. It's great that we know we can implement the CanMeds competencies into our system, but a bit disappointing we've let another country leapfrog us like that...

Second, when doing evaluations of students, it doesn't seem to matter too much what kind of system you use for that evaluation in terms of reproduce-ability. "Objective" evaluations don't hold up much better than clearly subjective evaluations. Rather, the main factor appears to be time, with the major cutoff being 4 hours. Most of our evaluations are less than that. Combining assessment approaches does seem to help, but only if they're attempting to evaluate the same overall goal.

Third, going along with the first two points, we seem to have a really good idea of how we can make medical education significantly better, but the research is well ahead of implementation. I'd blame this discrepancy on money, but none of the suggestions seemed to be all that resource-intensive, and even demonstrated some ways money could be saved. I think the major barrier is that the research isn't getting to many of the individuals making the big decisions in education, or to the extent that it is, these decision-makers aren't willing or able to make the rather large conceptual changes that medical education requires for improvement.

Medicine is still, unfortunately, a rather hierarchical field that would prefer to make a series of small changes than a few big ones. Medical education isn't much different. That couldn't have been more clear today.

I was very encouraged to see some educational leaders at my school in attendance at the conference. Unfortunately, many of them were already the converted leaders, the ones who probably need no convincing. There's still a long road ahead here.

Lastly, and a bit more topically, the keynote speaker emphasized the importance of non-standardized metrics for evaluating students. In medicine, these metrics are probably essential, though they're often shied away from both in terms of getting into medical school and in terms or getting through medical school. Being comfortable with non-standardized evaluations and implementing them appropriately is a smaller shift in medical education schools could start implementing immediately.

On the flip side, standardized metrics are also important. Having both standardized and non-standardized metrics is important to maintain flexibility in evaluations while warding against bias. This is particularly relevant for CaRMS applications, which currently employ completely non-standardized metrics. While introducing a standardized component to CaRMS would be a challenge, and not one without meaningful drawbacks, it's a something I believe deserves a bit more attention than it currently receives.

Quick Hockey Post!

I've got a real post coming soon, but with the NHL season starting very soon, I'll take the opportunity to make a completely-ignorable post on hockey!

I'll focus on two teams - Montreal (because I love the team) and Toronto (because I love to hate the team). These are two teams in very different situations. Montreal has been sniffing at the door of contending for a few years now, while Toronto has been solidly in the draft lottery. Likewise, Montreal is hoping to go deep into the playoffs, while Toronto is in the midst of a complete teardown.

Yet, they're both facing a very similar problem: they've signed too many mediocre players.

Toronto's angle here is clear - to fill their ranks with cheap, potentially disposable players who might be flipped for draft picks at the trade deadline (if they perform at or slightly above expectations) or signed to a longer-term deal (if they drastically exceed expectations). It's a good strategy that they've employed effectively in the past, pretty much the only thing that's kept their prospect pool half-decent despite years of fairly horrible draft decisions. Unfortunately, they've overdone it. Not counting Nathan Horton, who is permanently injured, they have 14 forwards signed - most to 1-year or otherwise expiring contracts - plus 8 D-men. Even if they send a few down to the AHL, it's a pretty crowded roster.

The main problem with this strategy is that there aren't many opportunities for development for those not already on NHL contracts. Kadri, JVR, Gardiner, & Rielly will benefit from some added responsibility this year, but players like Nylander and Connor Brown, who are sniffing at the edges of making the main squad are going to get shut out. Even an injury or two won't open a spot for them. Rushing players into the NHL is a mistake the Leafs have made far too often, but preventing young players from playing in the NHL when they're ready can be equally damaging. A few roster players are going to get marginalized as well. I like the signings of Boyes, Arcobello, Panik, and Matthias, as well as the trade for Grabner. These players could be part of the future of the Leafs, or just as easily could be flipped for asserts. Not all of them are likely to get much chance to shine in the current Leafs logjam.

Maybe the Leafs are still looking to move a player or two - Bozak and Lupul remain on the trade block. Maybe the plan is to bring these younger players up in more prominent roles after the trade deadline, when at least a few players are guaranteed to be shipped out. There might be a longer-term logic here, but in the short term, I just don't see it yet.

Montreal's approach is just nonsensical - for the past few years they've been good on depth but light on high-end talent outside of a few key players (Price, Subban, Pacioretty). For the most part, all they've done this past year is added more depth that they don't need. Semin is the one exception - he's a bit of a gamble, but he's a cheap way to potentially gain a solid top-6 forward, which Montreal desperately needs.

Montreal also has 14 forwards signed (though that might rise to 15 if Fleischmann gets the contract he appears to have earned) and while they only have 7 NHL D-men, those D-men are also fantastically expensive and sitting ahead of a much deeper bench of prospects. Plus, those players aren't likely to be traded at the deadline for draft picks - at best, they'll be traded for other players, similar to what happened with the acquisitions of Kassian and Smith-Pelly.

This simply means too many players fighting for too little opportunity. Just as with Toronto, some of these players really won't be given a chance. More importantly, Montreal's prospects are getting completely shut out. Hudon and Andrighetto are getting close. Tinordi has been in the AHL too long - if he's not playing with the big team or traded to another organization soon, he's at risk of becoming a wasted high-end prospect.

I'm still baffled about the acquisitions of Torrey Mitchell and Brian Flynn. Not that either player is bad - they're both capable bottom-6 players - but neither is likely to improve much moving forwards and there are another 6 equally capable players in the system that have higher potential that could be filling those roles. So what's their point?! If they make the team better now, it's a very marginal benefit, and they're not going to make Montreal better in the future.

The defense isn't any better - Petry, Emelin, and Gilbert are all fine bottom-4 defensemen, but so are Beaulieu and Pateryn, who are much cheaper with higher potential (aside from maybe Petry). And why'd they get rid of Mike Weaver? He was the perfect bottom-pairing D-man, cheap but reasonably effective, especially on the PK. Petry/Emelin/Gilbert/Beaulieu as the bottom-4 is probably better than say, Emelin/Beaulieu/Pateryn/Weaver would be this year, but not by all that much, and there's a lot more flexibility moving forward with the second group, not to mention a price difference of about $6 million. The Petry signing was, frankly, a mistake.

Anyway, it's been clear from this off-season that there's a lot more talent out there than there is money to pay them or positions on rosters to take them all. Good teams seem to have developed a strong, reliable core of players, then used free agents (including rentals), trades, and well-developed prospects to fill in the holes in their line-up on an as-needed basis. Chicago did that to win their cups. LA did that too. Boston did that. Anaheim's doing it now, as is Pittsburgh. It seems to be working for them. Toronto needs to develop the core, which the current strategy is standing in the way of. Montreal has the start of a core, but has now cut themselves off from filling in the holes effectively. This lack of flexibility could come back to bite both teams in the end.

All-Day Shifts Are Great When You Get Sleep

So, in my current rotation, OBGYN, there are two mandatory 26-hour shifts. I've now done both of them.

My first was crazy. Lots of deliveries, tons of obstetrics and gynecology patients to manage through the day, something new coming up every 15 minutes. For a good 12 hour stretch, I never sat down except to take a patient's history or catch a baby. Did manage to get about an hour and a half of sleep at 3 am or so, only because my resident (who, like pretty much all my residents, was great) seemed to take pity on me and let me nod off. When I woke up, it was back to running.

The next day was spent in a bit of a stupor - I couldn't concentrate on anything and had a wicked headache. I still felt tired the next morning when I had to show up for my next shift.

I've worked nights before, quite of few of them actually. I thought I was pretty well-prepared to handle these sorts of shifts. Turns out most of my coping involving my pre-night prep for the shift, which is fairly impossible on a 24+ hour shift.

So, I was a bit worried about how the second full-day shift would go. Well, had a very different experience, and that difference was sleep. The day overall was much quieter - fewer deliveries and far fewer consults. In some ways that's a bad thing, since adrenaline from running around was the main thing keeping me awake during my first shift. The upside, however, was that around 1 am, I got to go to sleep. For hours. Nothing came up until about 7 am when we started handover to the next group.

I still slept a bit when I got home, still felt a little bit out sorts, but basically had a real day of productivity after my full-day shift. Most importantly, I felt fully rested when I woke up for my next shift.

Anyway, just a friendly reminder - to myself as much as anything - that sleep is pretty important for your health.

Confusing Situations in Medical Specialty Job Markets

I've had a busy week, hence the low posting (more on that later, hopefully). However, I wanted to take a minute to discuss a phenomenon in the modern medicine job market that is endlessly baffling me: specialties with physicians who are simultaneously overworked and underemployed.

Underemployment in quite a few specialties has become an increasing concern. Resource-intensive specialties, especially surgical ones, are having the worst time. Neurosurgery, for example, has a notoriously terrible job market - across the country, positions are rare and demand ludicrously high qualifications. Yet in many of these specialties, practitioners are working insanely long hours, often have high stress levels, and in many cases, are rushing through patients at a rate that limits good patient care.

I can't help but see an obvious solution to this set of problems - let the overworked staff take on a little less responsibility, hire the desperate-for-work newly graduated physicians to take on some of the slack. Lower levels of stress for everyone involved, right?!

Yet, there are a lot of reasons this doesn't happen. Money is a big factor. Increasing the number of physicians working fully means higher health care costs. The physician's compensation is one part, but the support for these physicians is even more expensive, especially when it comes to surgeons. One figure I was quoted was that a new Cardiothoracic surgeon costs the health care system $1.5 million a year, but only a third of that or so goes to the surgeon. The rest goes to the administrative staff, the nursing staff, the research staff, and additional services needed to support that surgeon's work.

Now, if these new physicians were simply taking over work formerly done by other physicians, a good portion of the cost increase for additional physicians would be defrayed by lower costs of those other doctors. However, physicians generally don't want to work shorter hours - after all, many have the option, but choose not to. Each physician has their own reasons for the long hours, but here are the ones I've seen more-or-less directly.

1) Habit. Residents work insane hours. Consultant physicians are therefor used to these insane hours. They may be working 65 hours a week, but they're used to 80, so they think they're cutting back, even if they're still working rather long hours.

2) Career advancement. Physicians are, almost by definition, ambitious people. Being a fully trained doctor with employment is only the start in many fields. To move up means making an impact, which means more responsibilities, both in clinical and non-clinical settings. Those all take time. Even when the extra work is non-clinical, that crowds out the clinical time, leading to some jam-packed clinics.

3) Money. It matters for governments, but also for physicians. For everyone really, but there are some important financial factors specifically for physicians. Our careers start later with a substantial amount of debt. Most physicians are not salaried - they have to cover their own pensions, benefits, insurance, etc. Many also cover their own supplies, infrastructure, or support staff, meaning it costs a fair bit of money just to have the practice open.

Physicians are also notoriously poor money-managers. A good number of physicians don't save enough for their retirement and of those who do save enough, many invest poorly. High incomes but low wealth characterize many physicians' financial situations - they make a lot, but habitually spend most of it.

There's undoubtedly some greed in there as well. That's not meant to be a judgement, we all are greedy in our own ways and physicians are no different. Conspicuous consumption - buying expensive things to show you can buy expensive things - also seems to be a hallmark of a high-earning physicians.

Whatever the motivation, working less for physicians means earning less, so there's a strong incentive to keep hours up.

4) Preference. One thing I've noticed in my first bit of clerkship is that while long hours can be incredibly draining, I feel that drain mostly at home, not at the hospital.

At the hospital, while there's a lot of work, much of it quite stressful, there's also a lot of gratifying aspects. The work is intellectually stimulating, socially engaging, and can have some clear positive effects on others. There's a fair bit of direct, positive feedback - rarely from other physicians, mind you (unless you're a student!) - but certainly from patients. I said before that physicians are, almost to a person, ambitious. Most are also egotists. Getting thanked, being told that you're smart, or that you're a wonderful person simply for doing your job is like a drug. It's a drug that's very hard to give up.

At home, with rarely enough time to pull your share around the house, to be social with friends or family, to spend time with your partner, there's almost a recipe for failure. I'm incredibly lucky to have a supportive SO - which seems to be the major factor in keeping life together as a physician with long hours - but if there's a place I feel like I'm not quite living up to expectations, it's at home. This doesn't seem to be an uncommon sentiment among physicians and it creates a destructive cycle prone to workaholism. Physicians feel good at work, bad at home, so they spend more time at work. That makes work feel better and home feel worse, which in turn pushes these physicians to spend more time at work and so on.

The sum of all these effects is older physicians working longer than they need to, longer sometimes than they want to, all while younger physicians struggle to find enough work. While efforts are certainly underway to change this dynamic - financial counselling, more flexible work schedules, encouraging physicians to spend more time with their family - all of this does help to get physicians to take more time for themselves and in specialties with job shortages, frees up some work for new graduates. However, where these initiatives seem to be having the greatest effect are on those younger physicians looking for work, as well as on physicians in specialties that don't have shortages.

Point of this ramble (and wow, much longer post than I was expecting) is that while it's laudable to go the extra mile for your patients, long hours don't always equate to doing the best for your patients - or yourself.

Could We Shorten Medical Training Times?

A topic that comes up from time-to-time is whether training times for physicians are too long. After all, the typical family physician isn't able to practice until 10 years after finishing high school and specialists take 13 years. That's before fellowships. There's a fair bit of variability there - some candidates get in with only 3 years of undergrad and we have some 3-year medical schools, though many applicants take longer than 4 years after finishing high school before getting into medical school either because of years off, extra schooling, or simply because they don't get in when they apply in their 4th year of undergrad.

Still 10-13 years is the standard minimum, and that comes with numerous downsides. Long training times are economically disadvantageous both for students and the education system, resulting in less time as a fully-trained (and fully paid) physician and more time in a less-productive trainee role. This training time is worthwhile if it results in increased long-term productivity or effectiveness as a physician - education, after all, is an investment that presumably comes with returns on that investment. However, it's not hard to imagine that all those years come with some investments that don't pan out with any regularity and could be eliminated.

Long training times are hazardous for policy makers as well. Physician supply is a tricky balance to achieve under the best of circumstances - medicine is complex and uncertain, so determining what services are necessary or how many physicians are needed to provide those services is not an exact science. Nevermind the challenge of figuring out what type of physicians are necessary and where they should be located. With training times in their current state, any adjustments to physician supply don't even start to come into effect for about 7 years.

Say we need to train fewer physicians: the main way to do that is to accept fewer medical students. But, from the start of the application cycle until the first family physicians from that cohort are fully trained, it takes about 7 years. Same if we need to train more of one type of specialist and less of another - from the time medical students go through residency applications to the end of residency (plus the now near-mandatory fellowship), it's 6-8 years. If evaluating present needs in medicine is challenging, predicting the future is damned-near impossible. Ontario took a shot at it - the Ontario Population Needs-Based Physician Simulation Model - and while it has some good insights, on the whole it does a rather inconsistent job of predicting need (most egregiously, we don't have a giant shortfall of Diagnostic Radiologists - if anything, the job market is tight).

To summarize my ramble, there are good reasons to cut down training times if feasible. How could we go about this?

1) Reduce the post-high school, pre-medical school training times
There's no real absolute need for students to do as much post-secondary education before medical school. It's not a completely useless endeavour - plenty of knowledge gained in undergrad has utility in medical school or beyond, it's the best time to develop valuable skills for the future (even if those are simple things like studying or being organized), and it's also an important time of maturation. We expect a lot of physicians and learning how to be an adult on top of that is no small task.

Yet, a full four years of undergrad - or in some cases, more than that - probably isn't necessary for all applicants either. Accepting more students after third year, or exceptional students after second year, could shave a year or two off the total training time for physicians. However, given the competitiveness of medicine, older applicants will almost always have an advantage, given their additional time to mature and develop knowledge or skills, so the average impact on training time would likely be fairly minor.

Another option is to accept students right out of high school. Many countries, especially in Europe, do this already. Their medical schools are often longer with this route - 6 years is the standard, rather than Canada's 4. It's a plausible option: after all, physicians in these countries are well-trained and of high quality. However, there are also differences in the way medicine is practiced and how the educational system is structured, especially at the secondary level, that may make direct-from-high school programs problematic or less effective in Canada.

The current trial at such a strategy - Queen's QuARMS program - is not likely to give us many answers. By taking only 10 students, there's a very high likelihood that their students are not going to be representative of the high school population as a whole. If QuARMS proves problematic, that might mean something, because if even the best high school students struggle, the rest won't likely have much success. Yet, if these students succeed - and there's little reason to think they won't - it won't tell us much about whether it makes sense to switch to such a model.

There's an additional downside here. While overall training times for physicians would shorten somewhat, this approach actually lengthens the time it would take for policy changes to have an effect. Numbers of new physicians would be locked in about 9 years in advance, rather than 7.

2) Reduce the time in medical school
Most medical schools are 4 years long. Is this necessary? Absolutely not. How do I know? Two schools in Canada do just fine with 3 years.

Pre-clerkship does not need to be as long as it is at many schools. Too much of the information transmitted is of marginal value to the actual practice of medicine, important for a small subset of practitioners, or better learned in clerkship anyway. In addition, while summers are great for relaxation and extra-curriculars, they're also great for forgetting everything you learned in the school year. Cutting pre-clerkship in half would save a lot of money, shorten training times and doesn't seem to hurt educational outcomes.

There would be some downsides, however. Less time for ECs, research, and observerships means less opportunity to explore different specialties or to develop a broader career. Still, no one seems to care much about ECs, research can be done longitudinally during school, and most people don't settle on a specialty until clerkship anyway. The drawbacks to losing a year of pre-clerkship may not be overly meaningful in the long run.

In addition, cutting a year out of medical school would take a big reorganization, with plenty of bumps along the way, and schools are typically quite hesitant to cut anything they think is worthwhile. Expensive but proven is a safer option for schools to take. Still, it's an option we know that some schools have had reasonable success with.

3) Shorten training times after medical school
Perhaps the most controversial suggestion is to reduce the post-graduate training times for physicians. Residency is where the bulk of physician training happens. Both residents and practicing physicians are loathe to reduce residency times for fear of producing unprepared physicians.

Still, there may be potential to reduce overall training times. Some specialties seem to do alright with shorter training times in the US (though there aren't always comparable - for example, IM fills a much different role in the US than in Canada).

Improvements in education during residency also show some potential to speed the process along. Competency-based evaluations with a focus on simulation-based education has been put forward as a method to get residents competent faster.

It's also not as though physicians finish residency with nothing left to learn. The first year of independent practice is often as educational as the residency years and learning in medicine is an ongoing effort throughout a physician's career. Residents don't have to be perfect physicians when they finish up their formal training, they just need the experience and ability to practice safely.

A growing topic in post-graduate training for physicians is the growing necessity of fellowships. In the past, fellowships were optional - additional training physicians could take to develop specialized knowledge, allowing them to tailor their practice to their interests. However, fellowships - in some cases more than one - have become increasingly required to obtain any job at all, not just those that call for the super-specialized skills a fellowship typically develops. This can, and should, be addressed.

Unfortunately, the main mechanisms for addressing this education inflation are a better tailored supply of physicians, creating a bit of a chicken-and-the-egg scenario. Physician training times are too long because there are too many physicians in some specialties, but because training times are so long, reducing the number of physicians in those specialties is exceedingly difficult.


In summary, there's good reason to think about reducing training times for physicians, but no real easy answers. I think the first step should be to reduce medical schools from 4 years to 3 years by cutting out a year of pre-clerkship, reducing summers to no more than a month, and adjusting that time to focus on the bare essentials. Other options are worth exploring, if only tentatively, for their feasibility to reduce costs of investing in new physicians without reducing the payoff from that investment.

Good Doctors

Having worked in a hospital setting before medical school, going back to a classroom for pre-clerkship was a bit disheartening. Not only was I away from patients, but my interactions with physicians were rather impersonal and very academically-oriented. There wasn't much opportunity to physicians, well, being physicians. It made me fairly cynical, more cynical than I thought I was getting. When the best a physician could be to me was an adequate instructor in a course that at many times carried only a passing relevance to my eventual career, it became very easy to get judgmental or frustrated with the quality of the physicians - they didn't feel like physicians because they weren't acting like physicians.

Being in clerkship, getting to spend time with physicians and residents while they interact with their patients, and with each other, has really removed a lot of that cynicism. There are some really good doctors out there. Some REALLY good doctors.

Don't get me wrong, I'm also seeing a lot of parts of medicine - and of individual physicians - that I'm less than impressed by, but there have been more than a few instances of the past week and a half that have really put things in perspective. Medicine is difficult and nuanced, but seeing a master at work is like watching an Olympic gymnast do a crazy routine and stick the landing. It's baffling and gorgeous all at the same time. And an encouraging goal to aspire to.

Learning the Culture of Medicine

One of the great things about being in clerkship is learning the things about medicine no one ever writes down or says in a lecture, but which are fundamental parts of the current practice of medicine. This is the "Hidden Curriculum" of medicine, and the overall culture - especially the common attitudes expressed by practitioners - is a huge part of it.

I wrote before about work hours and that's part of the culture of medicine that's really been striking to me in this first week. I'm adjusting to workdays that are 10 hours minimum reasonably well, but looking at those who have already made that adjustment has been extremely eye-opening, particularly the residents. Us medical students think we have it tough, but the truth is that feeling mostly comes from a (relatively) cushy lifestyle beforehand. Residents are the real workhorses of the hospital, putting in long hours that combine the stress of having to teach us dopey medical students with the stress of having to please their overseeing physicians while learning new facts and procedures.

(Consultants are a bit of a mixed bag, largely depending on specialty. Some see a huge drop in work hours once they start independent practice. Some simply see a shift in responsibility after residency. Most - though not all - work longer than the typical medical student, not to mention a bunch of "extras" they have to work on, such as Continuing Medical Education, research interests, and administrative tasks. Their main advantage is some degree of control over their schedule - while medical students and residents pretty much do what they're told, consultants can say "no" to some things)

One story from my week that hit home with me (told to me by a former clerk) was a resident who fumbled a question they thought they should have known. Not a softball question, just something they should have read up on. They chastised themselves for not working hard enough, for not spending more of their free time reading. From my understanding, this was from a resident on a service where 60 hour weeks are on the lighter side of things - 80 is more typical.

To me, that's almost the definition of insanity. How can someone who works almost twice what a normal person with a full-time job does consider themselves to be not working hard enough!? Yet, that's the culture of medicine in many pockets of the field.

Now, don't get me wrong, this is starting to change, slowly. The idea that physicians would have lives outside of medicine or limits like a normal human being used to be treated with open hostility. We've now reached a state where having a decent life outside of work is acknowledged as a worthwhile, even admirable goal, but not one that should in any way impact a physician's commitment to medicine.

Every year, we get a talk from one of the higher-ups at my school who reminds us to maintain a life outside of medicine - to have hobbies, to get some exercise, to eat well, and to spend time with our friends and family. It's a great message that this person earnestly believes and says because they want us to have a happy life. Unfortunately, these talks also tend to come with a reminder that if we don't live up to the multitude of commitments the school has impressed upon us, and if we don't make the extra effort to be a good student, there will be negative consequences. These talks also tend to come during a time when the school is explaining a whole bunch of new responsibilities or tasks we didn't previously knew we had. Kind of makes it hard to do all the "life" things they talked about.

Having a life as a physician is basically a priority that gets routinely ignored. That's a big step up from the antagonism towards a balanced lifestyle that used to exist, but it's still not enough. We've got a long way to go.

First Week of Clerkship

I'm halfway through my first week of clerkship and I'm really enjoying it so far. I feel like I've learned more in 2 days (and actually learned it in a way that'll be retained) than I have in an average 2 weeks of pre-clerkship.

The challenging part is the hours. My first day was 11 hours in the hospital. My second was lighter, just a bit over 10. Now, I've worked a full 40-hour week, in healthcare, which is more that most of my classmates can say, so the actual "work" part of clerkship hasn't been hard at all to manage. Heck, because it's been so interesting, I come out of the hospital feeling energized. No, the trouble comes when faced with all the other challenges of life and having virtually no time to deal with them. In an 8 hour workday, if you sleep for 8 hours and travel/prep for work for 2 hours as I used to, that still leaves 6 hours or so to eat, do chores, run errands, and simply relax. With an 11 hour workday, that leaves only 3 hours.

Another big shift for me - I have a lot more domestic responsibilities now than when I worked in healthcare before medical school. Back then I wasn't living with my SO, though I am now. We also have a dog. So, for me that means a half-hour walk in the morning with the pup, and I like to spend at least half a hour to an hour catching up with my SO. You know, so she still knows that I'm alive and that we still live together. Important relationship stuff like that.

There's not much time for that sort of thing. Even after 10-11 hours at the hospital, the work doesn't stop there. I still have some EC responsibilities to deal with. I also have a fair bit of reading I'm expected to do each day. Those 3 hours of "free" time I have fall to less than 1 pretty quickly.

I've cut back on sleep a bit, down to a still-reasonable 6.5, though I hope to push that back up once I'm on some easier rotations.

The whole process has really made me want to go for a lifestyle-friendly specialty. It's not that I can't handle the long hours - to my surprise, I've actually been able to keep on top of things pretty well and as I said, I'm enjoying my time in the hospital. No, my fear is that I'll be able to think I can handle it, but really my life will be falling apart in ways I can't see or don't appreciate. My SO is very supportive and understanding, but 1 hour a day with her, usually while doing other work-related things, really isn't the kind of relationship either of us wants. It's also not what I'd consider a worthwhile life. Really, my fear is that I'll enjoy medicine so much, I'll forget about the rest of my life that I care about.

So, I'm trying to hold firm about crossing some interesting but high-workload specialties off my list. As much fun as working in medicine can be, it's no substitute for a happy, balanced life.

Tired Already

Clerkship hasn't even started yet - we're still in our Clerkship Orientation - and I'm already losing sleep. Granted, we've had a particularly packed orientation week and I've had a lot of other commitments eating up time with the transition to the new year, but yikes, I was hoping to start Clerkship at least with a normal level of rest!

The good thing about a hectic orientation week is that I at least feel reasonably prepared for what looks to be an even more hectic start to Clerkship. The next two weeks are going to be busy, busier than I think I have ever been. If I can get through it with my sanity intact I'll be in good shape for the foreseeable future - I'll start having lighter rotations and my extra-curricular commitments will start to drop off.

Hopefully that'll mean I can start sleeping a full 7-8 hours again! Hopefully...