Right around the turn of the millennium, provincial governments across Canada realized that we had been training too few doctors. Way too few. So they opened up a ton of new medical school spots, including a new medical school itself (NOSM), to fill the gap. Residency spots also expanded, with extra ones specifically for international medical graduates. The whole result was a rather massive and (by medical training standards) rapid increase in the number of trainees in medicine. In Ontario alone, 380 medical student spots were added between 2000 and 2010, up to 950 from a mere 570.
The overall merits of such a rapid expansion are complex and worth saving for a separate discussion, but for now I'd like to focus on one clear downside - trainee overload.
Despite all perceptions to the contrary, medicine isn't that tough. Each individual piece of knowledge or skill doesn't require super-human ability to accomplish. The challenge comes more from the volume of skills and knowledge required and the complexity of putting it all together in unanticipated or uncommon situations.
Acquiring this large volume of knowledge and skills requires an equally large volume of experiences. This is the major rationale behind long and intense training times. However, these factors are being undone by a greater increase in trainee volume. In medicine, patients are a resource, arguably the most important resource. If you're the only learner on a busy service, it's easy to maximize your experiences - you get first dibs on any interesting patients or on any procedures. You can perform to the maximum of your skill set and learn any appropriate new skills whenever an opportunity arises.
When there are more learners at your same level, you have to share. That means fewer procedures, fewer patients, fewer experiences. If the service you're on is particularly busy and there's more than enough to go around, that may not be as big a problem, but even then learning opportunities are not often maximized.
More consequentially, when there are more learners above your level, you get second billing. Rather than perform to the maximum of your skill set, you perform to the maximum of whatever's left over after your seniors have their experiences covered. That's a necessary set-up in these situations - we want senior trainees to be closer to competence than juniors, especially with respect to medical students who aren't necessarily set on a career course. Still, it does slow everything down, delaying trainee development and reducing volume or quality of important experiences. Something previously done by a senior resident is now done by a fellow; something previously done by a junior resident is now done by a senior resident; something previously done by a medical student is now done by a junior resident. Everyone can get set back a peg.
We haven't even hit the worst of it. Current PGY-5s and fellows came from classes that were, in total, 150 students smaller than today's class sizes in Ontario alone. As the PGY-1s and PGY-2s that came from larger classes move up, the competition for learning opportunities will only increase. International students, mostly Canadians studying abroad, are increasingly trying to do electives in Canada in the hopes of matching back.
Unfortunately, when we had the expansion of medical trainees, we didn't have an equal expansion in medical training sites. Most programs simply got bigger. Some efforts were made - NOSM opened up and satellite campuses opened up at many existing medical schools. These take advantage of larger (formerly) community hospitals to open up additional learning opportunities for medical students. Unfortunately, residency spots have not adjusted as quickly - with the exception of NOSM and many family medicine programs, there are only a handful of residency spots in these satellite campuses.
The optimistic side is that this situation should stabilize soon. No one is considering a further expansion of medical spots and there's rumblings that a decrease may be in order (no plans as of yet, to my knowledge). Residency spots have slightly declined and there's been a slow redistribution of spots to peripheral centers. There are only so many elective spots to go around, even if there are more and more interested international students, while schools are generally pretty careful about not giving those out frivolously.
It's a lesson in properly planning medical training - with such a complex system, all aspects need to be considered. Our current decision-making process is fairly fractured, with different actors responsible for different parts of the training process. Strong communication between these groups is vital moving forward.
Saturday 31 October 2015
Physician Names
I find it kind of interesting what physicians are called in the hospital, especially at various stages of training.
Residents are always called by their first names. Always. They've got the title "Dr." at this point, but using it except in official documents almost never gets used. The odd time I'll see a resident introduce themselves with the "Dr." title to patients, mostly to emphasize that despite looking young, they are in fact a doctor who will be responsible for their care, but it's not all that common. The trend I'm noticing is that particularly young-looking physicians, especially shorter women, do this more often, I assume to ward off the unfortunate assumption many patients will make that this person is their nurse or a medical student, not their doctor.
Fully-trained physicians almost always introduce themselves by their title and last name. Residents generally address them by their title, though there are certainly exceptions, especially in small programs. Nurses tend to move from title and last name to first name as they get older, which I think is a decent way to subtly convey seniority and keep physicians from getting too big of a head. After what is often 20 years of working, these nurses have more than earned the right to address their physician colleagues the same way those physicians address them (though it should arguably be equal from the start).
What I find especially interesting is how fully-trained physicians are referred to among residents and non-physicians. The first name seems to be used for physicians who are particularly liked, once again conveying a degree of familiarity. But the first name is also often used for physicians who are particularly disliked, almost as a way to knock them down a peg. Physicians who are neither loved nor hated get their title and last name used.
Fellows are another interesting case. In most cases, they're fully-qualified physicians, even though they're still in training. They've passed their certification tests, they can practice independently. Yet they're pretty much always referred to by their first names.
Anyway, nothing overly meaningful, just an interesting sociological pattern in the complex culture of medicine!
Residents are always called by their first names. Always. They've got the title "Dr." at this point, but using it except in official documents almost never gets used. The odd time I'll see a resident introduce themselves with the "Dr." title to patients, mostly to emphasize that despite looking young, they are in fact a doctor who will be responsible for their care, but it's not all that common. The trend I'm noticing is that particularly young-looking physicians, especially shorter women, do this more often, I assume to ward off the unfortunate assumption many patients will make that this person is their nurse or a medical student, not their doctor.
Fully-trained physicians almost always introduce themselves by their title and last name. Residents generally address them by their title, though there are certainly exceptions, especially in small programs. Nurses tend to move from title and last name to first name as they get older, which I think is a decent way to subtly convey seniority and keep physicians from getting too big of a head. After what is often 20 years of working, these nurses have more than earned the right to address their physician colleagues the same way those physicians address them (though it should arguably be equal from the start).
What I find especially interesting is how fully-trained physicians are referred to among residents and non-physicians. The first name seems to be used for physicians who are particularly liked, once again conveying a degree of familiarity. But the first name is also often used for physicians who are particularly disliked, almost as a way to knock them down a peg. Physicians who are neither loved nor hated get their title and last name used.
Fellows are another interesting case. In most cases, they're fully-qualified physicians, even though they're still in training. They've passed their certification tests, they can practice independently. Yet they're pretty much always referred to by their first names.
Anyway, nothing overly meaningful, just an interesting sociological pattern in the complex culture of medicine!
Wednesday 28 October 2015
On-Call Thoughts
Random thoughts from the middle of the night on-call:
1) Call rooms are like mini-hotel rooms and I love them. They're not much (pretty small, not overly fancy), but just the fact that they have a bed, a bathroom, a place to plug the phone in, and some privacy is awesome.
2) Call in Peds is completely different than call was in OB. OB call was basically just working at night - sleep was an unexpected luxury. Peds call still involves a fair bit of work, but sleep is more plentiful and much easier to predict.
3) The city looks oddly serene at nearly 3 am. My call room has a window and it truly looks like the whole place is asleep.
4) While maybe not the best idea, taking advantage of a middle-of-the-night wake up to do some homework feels oddly productive, though I'm not sure I got as much learning out of my efforts as I should have!
1) Call rooms are like mini-hotel rooms and I love them. They're not much (pretty small, not overly fancy), but just the fact that they have a bed, a bathroom, a place to plug the phone in, and some privacy is awesome.
2) Call in Peds is completely different than call was in OB. OB call was basically just working at night - sleep was an unexpected luxury. Peds call still involves a fair bit of work, but sleep is more plentiful and much easier to predict.
3) The city looks oddly serene at nearly 3 am. My call room has a window and it truly looks like the whole place is asleep.
4) While maybe not the best idea, taking advantage of a middle-of-the-night wake up to do some homework feels oddly productive, though I'm not sure I got as much learning out of my efforts as I should have!
Saturday 24 October 2015
Stressing Out About Electives Choices
I mentioned previously that my electives choices are coming up in a few months, faster than I expected. I am stressing out about them, way more than I probably should be. I can't even start to make my choices for electives yet, but I've reached a near-obsession state about planning them.
Here's my basic conundrum: do I choose electives to maximize my chances of getting my preferred spot in the CaRMS match, or do I choose electives to maximize my learning? In the end, it will be a balance of both, but how far to go down each path is giving me pause. All of this is complicated by the fact that I haven't yet chosen what my target specialty will be, though I'm getting closer.
Nothing has yet to really grab me as a must-do specialty though this isn't too surprising as I've always been leaning towards a generalist role in one way or another. There are bits of each specialty I've seen so far that I enjoy, but nothing that hits me overall as uniquely interesting. What has become clear is that I value having a degree of control over my career - location, practice type, hours, that sort of thing. (This makes Family Medicine a rather attractive choice, given its excellent job market, flexible practice option, wide scope of practice, and shorter residency. I'm not set on it quite yet, and I still have some reservations about the field, but the pros of Family Med are definitely starting to outweigh the cons)
Anyway, back to electives. I have 16 weeks to work with, essentially eight 2-week stints (or perhaps one 4-week and six 2-week rotations). I'd like to do at least 8 weeks in whatever specialty I'd think of ranking first, if only to get a sense of what programs are like across the country and to maximize my chances at a good reference letter. Ideally these would come earlier in the rotation, before I have to submit my CaRMS documents. That leaves 8 weeks or less for learning, mostly on the back-end of my electives time.
But, then I think, maybe more time in the main specialty is necessary to maximize chances of matching to a place I'll like. After all, in every program I'm thinking about, I have more than 4 programs that I think would be good fits. Doing some "learning" electives within that specialty could be useful too, particularly in areas I'm not too keen on matching into (like Nunavut! Sorry Nunavut, you're really interesting, but my dog would probably freeze up there...).
And then I go back again, thinking more learning time might be best, considering most specialties I'm looking at aren't that competitive. Some rotations I may never get a chance to see again, such as Dermatology, even though I have zero interest in becoming a Dermatologist (I've quickly learned skin stuff pops up all the freaking time and most physicians aren't that good with these issues). I could take a bit of a gamble on myself - most people do match to their top 3 programs anyway - and hope that I have enough exposure between my clerkship experiences and my electives to find a good fit. Whatever specialty I decide on, if there's a choice between improving my capability as a physician and advancing my career, I'd rather pick the former than the latter - if I can still land a career I'm reasonably happy with.
Anyway, you see my indecision, before I even have a decision to make. Fingers crossed the next few months provide some clarity here!
Here's my basic conundrum: do I choose electives to maximize my chances of getting my preferred spot in the CaRMS match, or do I choose electives to maximize my learning? In the end, it will be a balance of both, but how far to go down each path is giving me pause. All of this is complicated by the fact that I haven't yet chosen what my target specialty will be, though I'm getting closer.
Nothing has yet to really grab me as a must-do specialty though this isn't too surprising as I've always been leaning towards a generalist role in one way or another. There are bits of each specialty I've seen so far that I enjoy, but nothing that hits me overall as uniquely interesting. What has become clear is that I value having a degree of control over my career - location, practice type, hours, that sort of thing. (This makes Family Medicine a rather attractive choice, given its excellent job market, flexible practice option, wide scope of practice, and shorter residency. I'm not set on it quite yet, and I still have some reservations about the field, but the pros of Family Med are definitely starting to outweigh the cons)
Anyway, back to electives. I have 16 weeks to work with, essentially eight 2-week stints (or perhaps one 4-week and six 2-week rotations). I'd like to do at least 8 weeks in whatever specialty I'd think of ranking first, if only to get a sense of what programs are like across the country and to maximize my chances at a good reference letter. Ideally these would come earlier in the rotation, before I have to submit my CaRMS documents. That leaves 8 weeks or less for learning, mostly on the back-end of my electives time.
But, then I think, maybe more time in the main specialty is necessary to maximize chances of matching to a place I'll like. After all, in every program I'm thinking about, I have more than 4 programs that I think would be good fits. Doing some "learning" electives within that specialty could be useful too, particularly in areas I'm not too keen on matching into (like Nunavut! Sorry Nunavut, you're really interesting, but my dog would probably freeze up there...).
And then I go back again, thinking more learning time might be best, considering most specialties I'm looking at aren't that competitive. Some rotations I may never get a chance to see again, such as Dermatology, even though I have zero interest in becoming a Dermatologist (I've quickly learned skin stuff pops up all the freaking time and most physicians aren't that good with these issues). I could take a bit of a gamble on myself - most people do match to their top 3 programs anyway - and hope that I have enough exposure between my clerkship experiences and my electives to find a good fit. Whatever specialty I decide on, if there's a choice between improving my capability as a physician and advancing my career, I'd rather pick the former than the latter - if I can still land a career I'm reasonably happy with.
Anyway, you see my indecision, before I even have a decision to make. Fingers crossed the next few months provide some clarity here!
Monday 19 October 2015
Public Opinion on Resident Work Hours
Stumbled across this article while researching a completely unrelated topic. Basic idea is that public opinion on resident work hours is rather strongly in favour of suggested restrictions and even is in favour of far more restrictive work hour limits. American-focused, but still relevant here in Canada.
I'm not a huge fan of making policy decisions - in medicine or otherwise - based primarily on public opinion. After all, people can make poor decisions and large groups of people are not guard against poor decision-making. More specifically when it comes to resident work hours, the public probably lacks a degree of perspective necessary to formulate a well-informed viewpoint.
However, the disparity is striking, and demonstrates how out-of-touch the practice of medicine is with the rest of society. While physicians debate the merits of an 80 hour average week, with more than a few physicians coming out strongly against such restrictions, the majority of non-physicians would be in favour of a 60 (or even 50!) hour average week with 80 hours maximum in a week. These opinions were fairly broadly-held, not dependent on demographics or ideology.
What's currently being discussed in medicine in terms of work hours borders on what "normal" people would consider insane. Perhaps these long work hours are necessary due to other factors. Still, even if it is a necessity, it's increasingly hard to maintain the pretense that these hours should be considered manageable by any common standard. Patients don't think their physicians should be working such long hours - if we continue with the current work weeks, we'd better have a very good justification as to why it's necessary they do.
I'm not a huge fan of making policy decisions - in medicine or otherwise - based primarily on public opinion. After all, people can make poor decisions and large groups of people are not guard against poor decision-making. More specifically when it comes to resident work hours, the public probably lacks a degree of perspective necessary to formulate a well-informed viewpoint.
However, the disparity is striking, and demonstrates how out-of-touch the practice of medicine is with the rest of society. While physicians debate the merits of an 80 hour average week, with more than a few physicians coming out strongly against such restrictions, the majority of non-physicians would be in favour of a 60 (or even 50!) hour average week with 80 hours maximum in a week. These opinions were fairly broadly-held, not dependent on demographics or ideology.
What's currently being discussed in medicine in terms of work hours borders on what "normal" people would consider insane. Perhaps these long work hours are necessary due to other factors. Still, even if it is a necessity, it's increasingly hard to maintain the pretense that these hours should be considered manageable by any common standard. Patients don't think their physicians should be working such long hours - if we continue with the current work weeks, we'd better have a very good justification as to why it's necessary they do.
Sunday 18 October 2015
Vote!
Tomorrow's election day. You should vote. It's fun, you will feel good about contributing to our great country, and the nice people at your polling station will often thank you for doing something that's in your own freaking best interests to do.
So go vote!
So go vote!
Location, Location, Location
Faster than I expected, I'm starting to look at my 4th year electives. It's tough - there's not much time to work with, a lot of uncertainty about what kind of elective I can get, or even what electives I want to get. Not knowing exactly what specialty I want yet makes it that much more challenging...
Anyway, the reason I bring this up is that I've increasingly become aware of how difficult it is to control where you live when doing your training. I've always been told that one of the best ways to ensure the career you want is to be flexible about location. Be willing to move anywhere in the country and your chances of getting your first choice specialty are very high. Be willing to move anywhere in the country and you'll get the fellowship you want, or the job you want after that.
I'm willing to move. And I'm not particularly interested in the major city centers (Toronto, Montreal, Vancouver) that tend to be uber-competitive, so my chances of ending up where I want to are at least reasonable. However, while I'm willing to move if necessary, I'd rather not move around too much over the next few years. In some career pathways, moving 4 times within a decade, potentially halfway across the country, is very plausible. For example, both Internal Medicine and Pediatrics go for three years before their subspecialty matches, each of which are typically followed by a 1-year fellowship before finding employment. That's potentially one move for residency, one move for subspecialty, one move for fellowship, and one move for work. Four potential moves total, assuming no second fellowship or locum work, both of which are entirely possible.
Granted, staying at one institution between med school and residency, residency and subspecialties, subspecialties and fellowship, and/or fellowship and employment is often an option. Most students do their residency at their home schools, after all. However, staying put isn't always a possibility. Not every residency, subspecialty, or fellowship exists at every school. Jobs aren't always easy to come by in locations with residency programs. The programs that exist where I want to stay may not be high-quality or tailored to my needs. They may not want me as a resident/fellow/employee either.
That's giving me a lot of pause when it comes to considering a long-term career pathway. If I'm going to move for residency, I'd rather not set myself up to have to move for a subspecialty or for fellowships. That's easier said than done, especially outside the competitive large cities.
This realization is also exposing a fairly fundamental conflict in my career/life planning. I'm ambitious, but I also work to live, not live to work. Optimizing my career goals means moving, a lot. Optimizing my life outside of my career means moving as little as possible. I'm not sure how easily I'll be able to find that balance.
Yet, finding that balance is now the goal. As a plan my electives, I also start to set my career path in motion. I've only got 16 elective weeks to find locations/programs that fit me well, fit my family well, and have some desirable career options moving forward. These weeks are also my best opportunities to show those programs that they should want me in their programs. Choosing electives may be the first "career" decision I've truly had to make so far since starting medical school, and I'm just now recognizing what kind of an impact these choices might have. Fingers crossed I make some good decisions!
Anyway, the reason I bring this up is that I've increasingly become aware of how difficult it is to control where you live when doing your training. I've always been told that one of the best ways to ensure the career you want is to be flexible about location. Be willing to move anywhere in the country and your chances of getting your first choice specialty are very high. Be willing to move anywhere in the country and you'll get the fellowship you want, or the job you want after that.
I'm willing to move. And I'm not particularly interested in the major city centers (Toronto, Montreal, Vancouver) that tend to be uber-competitive, so my chances of ending up where I want to are at least reasonable. However, while I'm willing to move if necessary, I'd rather not move around too much over the next few years. In some career pathways, moving 4 times within a decade, potentially halfway across the country, is very plausible. For example, both Internal Medicine and Pediatrics go for three years before their subspecialty matches, each of which are typically followed by a 1-year fellowship before finding employment. That's potentially one move for residency, one move for subspecialty, one move for fellowship, and one move for work. Four potential moves total, assuming no second fellowship or locum work, both of which are entirely possible.
Granted, staying at one institution between med school and residency, residency and subspecialties, subspecialties and fellowship, and/or fellowship and employment is often an option. Most students do their residency at their home schools, after all. However, staying put isn't always a possibility. Not every residency, subspecialty, or fellowship exists at every school. Jobs aren't always easy to come by in locations with residency programs. The programs that exist where I want to stay may not be high-quality or tailored to my needs. They may not want me as a resident/fellow/employee either.
That's giving me a lot of pause when it comes to considering a long-term career pathway. If I'm going to move for residency, I'd rather not set myself up to have to move for a subspecialty or for fellowships. That's easier said than done, especially outside the competitive large cities.
This realization is also exposing a fairly fundamental conflict in my career/life planning. I'm ambitious, but I also work to live, not live to work. Optimizing my career goals means moving, a lot. Optimizing my life outside of my career means moving as little as possible. I'm not sure how easily I'll be able to find that balance.
Yet, finding that balance is now the goal. As a plan my electives, I also start to set my career path in motion. I've only got 16 elective weeks to find locations/programs that fit me well, fit my family well, and have some desirable career options moving forward. These weeks are also my best opportunities to show those programs that they should want me in their programs. Choosing electives may be the first "career" decision I've truly had to make so far since starting medical school, and I'm just now recognizing what kind of an impact these choices might have. Fingers crossed I make some good decisions!
Saturday 17 October 2015
(Fake) War is H-E-L-L
So, just finished up a game of Laser Quest where I was the only person old enough to get a driver's licence (full disclosure, I was supervising one of the children there, wasn't just a weird old guy hanging out with a bunch of pre-teens). I destroyed those small children, beating the second place finisher by around 300 points and nearly doubling the score of the third place finisher.
Am I making a post just to brag about my superiority over children who can barely hold up their lasers? Well, mostly yes. I take an odd pride in my Laser Quest ability, and I don't care if they were 2 feet shorter than me, I crushed them!
But, the other point is that we all grow up too fast and doing kid stuff every once in a while is a whole lot of fun.
(Side point - the kids all had a good time, even the ones I wouldn't stop shooting. And the parents of the kids all had a good laugh when I somewhat sheepishly accepted my first-place scorecard while towering over all the other competitors.)
Am I making a post just to brag about my superiority over children who can barely hold up their lasers? Well, mostly yes. I take an odd pride in my Laser Quest ability, and I don't care if they were 2 feet shorter than me, I crushed them!
But, the other point is that we all grow up too fast and doing kid stuff every once in a while is a whole lot of fun.
(Side point - the kids all had a good time, even the ones I wouldn't stop shooting. And the parents of the kids all had a good laugh when I somewhat sheepishly accepted my first-place scorecard while towering over all the other competitors.)
Monday 12 October 2015
Work Hour Restrictions
Continuing on with my recent theme of super-long hours in the hospital, partially for myself, but mostly for my residents, it's worth mentioning the big elephant in the room for Canadian residency programs: resident work hour restrictions.
Long work hours have been identified as a potential cause of a lot of problems in medicine, both for providers and receivers of that care. The obvious solution then is to have providers - in particular the overworked residents - spend fewer hours on the job. While most countries with similar residency systems have implemented some form of work hour restrictions, Canada has not outside of Quebec. As such, it remains a topic of rather passionate debate, with fairly strong, opposing viewpoints from those at all levels of training.
Canadian practitioners are most familiar with how work hour restrictions came to be in the US, which were first implemented nationwide in 2003. The initial impetus for this change came from the death of Libby Zion, who, under the care of two overworked junior residents, was given a medication that when combined with her normal daily medications, resulted in a life-threatening condition that was not caught and eventually resulted in her death. The argument for work hour restrictions was fairly straight-forward: tired residents cannot deliver optimal care, so capping their hours (along with other restrictions on the distribution of those hours) will lead to more rested, more capable residents who would minimize mistakes for patients. There is more than enough evidence to support the notion that overworked or exhausted individuals are not the greatest workers and are prone to mistakes
The other justification, not always mentioned prominently in the debate, was to maintain the health and well-being of those residents. After all, residents are people too, who shouldn't be worked to the point of exhaustion. There is also quite a bit of evidence that long work hours contribute to medical or personal problems.
The argument against work hour restrictions was equally straight-forward: experience is the only way to make a competent physician, so work hour restrictions mean missed learning opportunities and less-competent physicians. There is also a large body of evidence for this argument, particularly in surgical specialties. You can't be competent with a surgical procedure until you've done it over and over again, so missed opportunities to scrub in add up.
It's now been 12 years since the first round of American work hour restrictions went into place and they've received a fair bit of scrutiny. The result? On all three points of consideration - patient outcomes, resident fatigue, and resident competency - the answer seems to be... mmmaaaaayyyybe...? In all respects, there seem to be studies which say work hour restrictions hurt, some which say they help, some which say they didn't make much different. On the whole, the answer seems to be that residents provide the same level of care, are just as tired, and just as competent as they were before the work hour restrictions.
Many of these studies come with fairly significant problems. With strong opinions on the subject being rather prevalent, bias in study design or result interpretation is a major concern that is difficult to address. Another large limitation is that actual hours worked before and after is rarely investigated. Some studies simply looked at results before and after the work hour restriction policy was put in place, without considering what effect that policy actually had on hours worked. Others used self-reported hours from residents which, as later investigations demonstrated, were often falsified to make it look like programs were in compliance with the regulations when they were routinely going over limits. Hard to see a change in outcome without a change in inputs.
A further criticism was that the work hour restrictions were still fairly permissive - 80 hours per week averaged over 4 weeks was the major cutoff. That's an average of about 11 and a half hours each and every day of the week, including weekends - hardly a light schedule. There were some other restrictions, such as 10 hours off between shifts, shifts that couldn't be longer than 24 hours (with an additional 6 for handover/education), one day off every week (on average) that were meant to make things a bit more palatable, but we're still not talking anything close to a 9-5 or even 7-5 job with weekends off.
There are also a lot of confounding factors when it comes to studying these interventions, which haven't been well addressed in previous literature. First is the challenge of handing over patients. Medicine sucks at transferring care between practitioners - it's a major opportunity for errors. When residents are prevented from working long shifts, it leads to more transfers of care, and more opportunities for mistakes to happen. The obvious response here is "fix the transfers", but that's easier said than done, so it remains a valid confounder. Another wrinkle in the intended effect of work hour restrictions is that residents don't always sleep when given more time. With 80+ hour work weeks, residents weren't just lacking sleep, they were lacking time to exercise, socialize, eat well, do domestic duties, spend time with their partner and/or children, whatever was important to them outside of medicine. When given the chance to spend less time at the hospital, sleep wasn't always the priority.
Unofficial duties also pop up outside the official work week. Every resident studies on their own time. Many participate in educational projects or research. "Homework" of a sort is pretty common. From my own experience, part of the challenge of dealing with 11 hour workdays is that I do 1-3 hours of studying, schoolwork, or EC tasks when I get home in the evening. In an environment where career opportunities are much less available than in the past, the impetus to go above and beyond, including using spare time, may eat up some extra time off.
When I started looking into the issue of resident work hours, my incoming opinion was that work hour restrictions were a painfully obvious solution to a painfully obvious problem. Given the available evidence, flawed as it may be, it's hard to maintain that view - work hour restrictions are not the disaster the detractors predicted, but neither is it a magic bullet. There are too many other factors to resident fatigue that need to be addressed in conjunction with work hours. We should be trying alternative approaches to reduce resident fatigue and evaluating them as intensely as we have work hour restrictions. In conjunction with or perhaps even in place of work hour restrictions, alternative approaches may provide the fatigue reduction many residents clearly need. It's hard to fathom that someone can work over 80 hours a week and be well-rested - there's simply no substitute for a good night's sleep - but I'm open to the idea if I can see some convincing evidence.
However, what are the alternatives? Safe transportation has come up, to prevent tired residents from driving home, but this is expensive and for many residents, costly in terms of time - a 15 minute drive home means more sleep than a 45 minute bus ride, for example. Another option, though not one I'd consider ethical, is medication. Some stimulants have been shown to improve wakefulness for tired workers, but sets a very dangerous precedent if it were to become compulsory. Past that, most discussions on this subject don't often provide realistic alternatives to improving resident fatigue. We should be open to any reasonable solutions to improving resident fatigue, but without workable alternatives to consider, effective implementation of resident work hour restrictions may be the only option for the moment, even if as a first step. Work hour restrictions may not be sufficient, and may not be optimally implemented in some jurisdictions, but they just might be necessary. Canada should consider an evidence-based approach to reducing resident working hours.
Long work hours have been identified as a potential cause of a lot of problems in medicine, both for providers and receivers of that care. The obvious solution then is to have providers - in particular the overworked residents - spend fewer hours on the job. While most countries with similar residency systems have implemented some form of work hour restrictions, Canada has not outside of Quebec. As such, it remains a topic of rather passionate debate, with fairly strong, opposing viewpoints from those at all levels of training.
Canadian practitioners are most familiar with how work hour restrictions came to be in the US, which were first implemented nationwide in 2003. The initial impetus for this change came from the death of Libby Zion, who, under the care of two overworked junior residents, was given a medication that when combined with her normal daily medications, resulted in a life-threatening condition that was not caught and eventually resulted in her death. The argument for work hour restrictions was fairly straight-forward: tired residents cannot deliver optimal care, so capping their hours (along with other restrictions on the distribution of those hours) will lead to more rested, more capable residents who would minimize mistakes for patients. There is more than enough evidence to support the notion that overworked or exhausted individuals are not the greatest workers and are prone to mistakes
The other justification, not always mentioned prominently in the debate, was to maintain the health and well-being of those residents. After all, residents are people too, who shouldn't be worked to the point of exhaustion. There is also quite a bit of evidence that long work hours contribute to medical or personal problems.
The argument against work hour restrictions was equally straight-forward: experience is the only way to make a competent physician, so work hour restrictions mean missed learning opportunities and less-competent physicians. There is also a large body of evidence for this argument, particularly in surgical specialties. You can't be competent with a surgical procedure until you've done it over and over again, so missed opportunities to scrub in add up.
It's now been 12 years since the first round of American work hour restrictions went into place and they've received a fair bit of scrutiny. The result? On all three points of consideration - patient outcomes, resident fatigue, and resident competency - the answer seems to be... mmmaaaaayyyybe...? In all respects, there seem to be studies which say work hour restrictions hurt, some which say they help, some which say they didn't make much different. On the whole, the answer seems to be that residents provide the same level of care, are just as tired, and just as competent as they were before the work hour restrictions.
Many of these studies come with fairly significant problems. With strong opinions on the subject being rather prevalent, bias in study design or result interpretation is a major concern that is difficult to address. Another large limitation is that actual hours worked before and after is rarely investigated. Some studies simply looked at results before and after the work hour restriction policy was put in place, without considering what effect that policy actually had on hours worked. Others used self-reported hours from residents which, as later investigations demonstrated, were often falsified to make it look like programs were in compliance with the regulations when they were routinely going over limits. Hard to see a change in outcome without a change in inputs.
A further criticism was that the work hour restrictions were still fairly permissive - 80 hours per week averaged over 4 weeks was the major cutoff. That's an average of about 11 and a half hours each and every day of the week, including weekends - hardly a light schedule. There were some other restrictions, such as 10 hours off between shifts, shifts that couldn't be longer than 24 hours (with an additional 6 for handover/education), one day off every week (on average) that were meant to make things a bit more palatable, but we're still not talking anything close to a 9-5 or even 7-5 job with weekends off.
There are also a lot of confounding factors when it comes to studying these interventions, which haven't been well addressed in previous literature. First is the challenge of handing over patients. Medicine sucks at transferring care between practitioners - it's a major opportunity for errors. When residents are prevented from working long shifts, it leads to more transfers of care, and more opportunities for mistakes to happen. The obvious response here is "fix the transfers", but that's easier said than done, so it remains a valid confounder. Another wrinkle in the intended effect of work hour restrictions is that residents don't always sleep when given more time. With 80+ hour work weeks, residents weren't just lacking sleep, they were lacking time to exercise, socialize, eat well, do domestic duties, spend time with their partner and/or children, whatever was important to them outside of medicine. When given the chance to spend less time at the hospital, sleep wasn't always the priority.
Unofficial duties also pop up outside the official work week. Every resident studies on their own time. Many participate in educational projects or research. "Homework" of a sort is pretty common. From my own experience, part of the challenge of dealing with 11 hour workdays is that I do 1-3 hours of studying, schoolwork, or EC tasks when I get home in the evening. In an environment where career opportunities are much less available than in the past, the impetus to go above and beyond, including using spare time, may eat up some extra time off.
When I started looking into the issue of resident work hours, my incoming opinion was that work hour restrictions were a painfully obvious solution to a painfully obvious problem. Given the available evidence, flawed as it may be, it's hard to maintain that view - work hour restrictions are not the disaster the detractors predicted, but neither is it a magic bullet. There are too many other factors to resident fatigue that need to be addressed in conjunction with work hours. We should be trying alternative approaches to reduce resident fatigue and evaluating them as intensely as we have work hour restrictions. In conjunction with or perhaps even in place of work hour restrictions, alternative approaches may provide the fatigue reduction many residents clearly need. It's hard to fathom that someone can work over 80 hours a week and be well-rested - there's simply no substitute for a good night's sleep - but I'm open to the idea if I can see some convincing evidence.
However, what are the alternatives? Safe transportation has come up, to prevent tired residents from driving home, but this is expensive and for many residents, costly in terms of time - a 15 minute drive home means more sleep than a 45 minute bus ride, for example. Another option, though not one I'd consider ethical, is medication. Some stimulants have been shown to improve wakefulness for tired workers, but sets a very dangerous precedent if it were to become compulsory. Past that, most discussions on this subject don't often provide realistic alternatives to improving resident fatigue. We should be open to any reasonable solutions to improving resident fatigue, but without workable alternatives to consider, effective implementation of resident work hour restrictions may be the only option for the moment, even if as a first step. Work hour restrictions may not be sufficient, and may not be optimally implemented in some jurisdictions, but they just might be necessary. Canada should consider an evidence-based approach to reducing resident working hours.
Friday 9 October 2015
My Amazing Residents
I'm getting towards the end of my first rotation. Something that deserves says - residents are awesome.
I've been hating the long hours - they work longer hours.
There's been a ton for me to learn in a short period of time - they have more to learn.
It's challenging to work and learn under others' directions, subject to their somewhat inconsistent whims - residents not only experience the same, but they teach us, having to adapt to our personalities and learning needs, all at the same time.
And they've been nothing but pleasant to me the whole time. They've often gone out of their way to teach me new things, or to get me in on useful clinical opportunities, or to let me practice a skill. So I wanted to take a quick second to send out a big "thank you" to all the residents who have helped me and tolerated my ignorance thus far. It really does make a difference.
I've been hating the long hours - they work longer hours.
There's been a ton for me to learn in a short period of time - they have more to learn.
It's challenging to work and learn under others' directions, subject to their somewhat inconsistent whims - residents not only experience the same, but they teach us, having to adapt to our personalities and learning needs, all at the same time.
And they've been nothing but pleasant to me the whole time. They've often gone out of their way to teach me new things, or to get me in on useful clinical opportunities, or to let me practice a skill. So I wanted to take a quick second to send out a big "thank you" to all the residents who have helped me and tolerated my ignorance thus far. It really does make a difference.
Sunday 4 October 2015
Likes and Dislikes In OBGYN
My first clerkship rotation has been OBGYN. I chose to start here because while OBGYN is on my list of specialties I'm considering matching to, it's not high on my list, so I don't feel too much pressure to perform. I've been able to focus on just adapting to clerkship and learning as much as I can. OBGYN is also one of the tougher rotations in clerkship, so it's a good place to set the tone for the rest of the year - with the exception of Surgery (which I won't have until the summer), it only gets easier from here.
Anyway, I've learned a lot in my first rotation, but here are my major discoveries:
1) I am not a surgeon
Ok, there's a long-standing controversy about whether OBGYNs are surgeons. Surgeons often say no. I'm betting if anyone outside of medicine saw what OBGYNs do, they'd call them surgeons based off the very simple criteria that they perform surgeries! With scalpels and cutting and everything! Now, that doesn't mean they're surgeons in the same way a General Surgeon is a surgeon - they clearly have less OR time in training and perform a relatively small variety of surgeries - but it's hard to say they're not surgeons at all.
Anyway, long story short, I'm not a surgeon. Didn't think I was going into things, but this basically confirmed it. Learning how to scrub in and go through the whole "now I put my hands and sharp objects into your body" ritual was fun, but the novelty wore off quickly. I'm just not enthralled enough by the anatomy or by the minutiae of what to dissect where, how, using what instruments and what sutures to employ when. It's not that I'm opposed to surgery, it was interesting enough, but I don't love it and with the long hours necessary to become a surgeon, I think you have to love it, at least a little bit. Which brings me to my next point...
2) Long hours probably aren't a fit for me
OBGYN involves some fairly crazy hours by regular-person standards. 50-60 hour weeks were pretty much the norm and even as a student, had a few that pushed closer to 80. That's 12 hours every weekday, plus 20 hours on the weekend. Night shifts are frequent and the work doesn't end when you get home - assignments, reading, and ECs still are there to take up what little time is left. Hard to complain though, residents definitely worked longer than I did.
I think I've managed pretty well. I've stayed quite active during pre-clerkship, so it wasn't like I was going from 30 hours of work a week to 60, more like going from a flexible 50-60 hour week with a short travel time to an inflexible 50-60 hour week with a longer travel time and some extra work added on. I also have plenty of experience with night shifts, something many of my classmates have never had outside of pulling an all-nighter while studying (which, for the record, is a really bad way to study). I've also worked a regular, full-time job in healthcare before.
Looking at my classmates, some are definitely having difficult adjusting. One or two also seem to be thriving, though it's hard to tell if that's more for show than a reflection of reality. So I don't think I'm doing too bad overall.
Now, could I handle this over the course of a full year, or a 5-year residency, or longer? I don't know. But, more importantly, I don't want to know. I've been managing, but this has been stressful. I'm not sleeping long enough, I have very little time to do the extra-curricular work I enjoy, let alone relax. I've been able to spend some time with friends and family by putting a priority on it, but that's about all.
As much as I want a good career, I want that as part of a good life overall. Even over the next 7 years - the time it would take me to finish a 5 year residency - I have some fairly significant life goals I'd like to work towards outside of medicine. I have no interest in sacrificing a good life for a good career, so keeping my working hours reasonable, both during residency and afterwards, is a big goal for me.
3) I love Obstetrics - Gynecology not so much
I'm really enjoying obstetrics. It's structured, from start to finish, which makes it easy to wrap my head around. It's a very hopeful field of work. From pre-conception planning all the way to deliveries, there are challenges for patients but ones that can be overcome. You can really feel like you're helping these women through a tough, but rewarding part of life. Usually there's a good ending. Even when there's not, there's a lot you can do as a physician to help, even if it's just on the emotional side of things. Overall, it's a very human part of medicine.
Gynecology also had a good bit of that human side of things, but the medicine was far less structured. The outcomes were often intangible and not nearly as good. Worse, there wasn't much that could be done for those with poorer results. There was nothing really wrong with this - it's pretty par for the course in many fields of medicine, and there is a lot that can be done to help patients in gynecology - but it wasn't as engaging as obstetrics, for me at least.
4) The happiness test
A piece of advice I got towards the start of clerkship when considering a specialty was "Go where the happy people are". It's a mantra I've heard repeated in many forms in only the first few weeks of clerkship and one I'm definitely buying into.
So, are OBGYNs happy? I'd say a qualified "yes".
The median person seems to be fatigued but still making jokes. On the ends of the spectrum of happiness are people who seem to have lost one of those traits. There were some super-happy people who don't seem to register fatigue, and more than a few who weren't joking around much. So, on the whole, I'd say OBGYNs are happy, but it's not a clear "yes". We'll see how that stacks up against other specialties!
Anyway, I've learned a lot in my first rotation, but here are my major discoveries:
1) I am not a surgeon
Ok, there's a long-standing controversy about whether OBGYNs are surgeons. Surgeons often say no. I'm betting if anyone outside of medicine saw what OBGYNs do, they'd call them surgeons based off the very simple criteria that they perform surgeries! With scalpels and cutting and everything! Now, that doesn't mean they're surgeons in the same way a General Surgeon is a surgeon - they clearly have less OR time in training and perform a relatively small variety of surgeries - but it's hard to say they're not surgeons at all.
Anyway, long story short, I'm not a surgeon. Didn't think I was going into things, but this basically confirmed it. Learning how to scrub in and go through the whole "now I put my hands and sharp objects into your body" ritual was fun, but the novelty wore off quickly. I'm just not enthralled enough by the anatomy or by the minutiae of what to dissect where, how, using what instruments and what sutures to employ when. It's not that I'm opposed to surgery, it was interesting enough, but I don't love it and with the long hours necessary to become a surgeon, I think you have to love it, at least a little bit. Which brings me to my next point...
2) Long hours probably aren't a fit for me
OBGYN involves some fairly crazy hours by regular-person standards. 50-60 hour weeks were pretty much the norm and even as a student, had a few that pushed closer to 80. That's 12 hours every weekday, plus 20 hours on the weekend. Night shifts are frequent and the work doesn't end when you get home - assignments, reading, and ECs still are there to take up what little time is left. Hard to complain though, residents definitely worked longer than I did.
I think I've managed pretty well. I've stayed quite active during pre-clerkship, so it wasn't like I was going from 30 hours of work a week to 60, more like going from a flexible 50-60 hour week with a short travel time to an inflexible 50-60 hour week with a longer travel time and some extra work added on. I also have plenty of experience with night shifts, something many of my classmates have never had outside of pulling an all-nighter while studying (which, for the record, is a really bad way to study). I've also worked a regular, full-time job in healthcare before.
Looking at my classmates, some are definitely having difficult adjusting. One or two also seem to be thriving, though it's hard to tell if that's more for show than a reflection of reality. So I don't think I'm doing too bad overall.
Now, could I handle this over the course of a full year, or a 5-year residency, or longer? I don't know. But, more importantly, I don't want to know. I've been managing, but this has been stressful. I'm not sleeping long enough, I have very little time to do the extra-curricular work I enjoy, let alone relax. I've been able to spend some time with friends and family by putting a priority on it, but that's about all.
As much as I want a good career, I want that as part of a good life overall. Even over the next 7 years - the time it would take me to finish a 5 year residency - I have some fairly significant life goals I'd like to work towards outside of medicine. I have no interest in sacrificing a good life for a good career, so keeping my working hours reasonable, both during residency and afterwards, is a big goal for me.
3) I love Obstetrics - Gynecology not so much
I'm really enjoying obstetrics. It's structured, from start to finish, which makes it easy to wrap my head around. It's a very hopeful field of work. From pre-conception planning all the way to deliveries, there are challenges for patients but ones that can be overcome. You can really feel like you're helping these women through a tough, but rewarding part of life. Usually there's a good ending. Even when there's not, there's a lot you can do as a physician to help, even if it's just on the emotional side of things. Overall, it's a very human part of medicine.
Gynecology also had a good bit of that human side of things, but the medicine was far less structured. The outcomes were often intangible and not nearly as good. Worse, there wasn't much that could be done for those with poorer results. There was nothing really wrong with this - it's pretty par for the course in many fields of medicine, and there is a lot that can be done to help patients in gynecology - but it wasn't as engaging as obstetrics, for me at least.
4) The happiness test
A piece of advice I got towards the start of clerkship when considering a specialty was "Go where the happy people are". It's a mantra I've heard repeated in many forms in only the first few weeks of clerkship and one I'm definitely buying into.
So, are OBGYNs happy? I'd say a qualified "yes".
The median person seems to be fatigued but still making jokes. On the ends of the spectrum of happiness are people who seem to have lost one of those traits. There were some super-happy people who don't seem to register fatigue, and more than a few who weren't joking around much. So, on the whole, I'd say OBGYNs are happy, but it's not a clear "yes". We'll see how that stacks up against other specialties!
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