I've missed the boat by a few weeks, but the 4th years were all busy in the hospital getting their CaRMS applications in. Very excited for them, especially the many excellent students I've worked with in clerkship. I'm particularly thankful to the elective student who was with me on my first week, they were an enormous help in getting adjusted to all things clerkship - while I hope everyone gets a residency they'll enjoy, I have to send extra good vibes to this person.
Ok, enough about other people! Me time! Ok not really, I'm really excited for the 4th years I know going through CaRMS, just couldn't think of a better segue.
I've been giving a lot of thought to my career in the short- and long-term given what I've learned from my time in clerkship. As I'm basically a single year from my CaRMS applications and specialty choice is a fairly important part determining my career direction, I've been narrowing down my options pretty quickly.
I'm finishing up my Pediatrics rotation now. I wanted it early because it was essentially at the top of my specialty list when clerkship started. It has a lot of practice options, there's a fairly holistic approach, people who work in Peds are generally good-spirited, and I really like working with kids. I had a good rotation, minus the traditional Peds rotation illnesses. My residents have been great, the kids were awesome to work with, the medicine was interesting. Yet, Peds is no longer my #1 choice.
As much as I liked Peds, I didn't love it either, and it comes with some downsides. Still not big on inpatient medicine, which is a huge part of Peds residency (consultants have some choice on this). The hours, while not nearly as bad as OBGYN, are still fairly long, with frequent overnight calls (that also gets better once becoming a consultant). The job market is pretty tight for Peds specialists, and I'd have to move a lot to pursue subspecialty training, likely to places I don't particularly want to go. I liked Peds ER, and that was definitely something I was thinking about beforehand, but I don't know for how long I'd be able to handle true shift work. It's not terrible now, but I don't think I'd be comfortable with the chaotic schedule in 10-15 years. If I could get regular shifts week-to-week that'd be one thing, but it's just a very messy arrangement. That pretty much leaves Community Pediatrics, which was also something pretty high on my list. It hits many of my preferences and has a decent job market.
The other specialty I'm considering is Family Medicine. While it's not the only difference, the main contrast between FM and Community Peds is simply patient population. One deals with all ages, the other is kids only. I like working with kids. I also like working with adults, including the elderly. Do I like working with kids more? Maybe. Not totally sure. But I know the difference isn't substantial, if one exists at all. It's pretty much a wash to me in terms of final working conditions.
So it comes back to residency. 2 years vs 4 years. Primarily outpatient vs primarily inpatient. Non-competitive vs competitive entry. Variety of locations vs only major centres.
A common refrain I hear from staff and residents is that you shouldn't avoid a specialty you like because the residency sucks. I appreciate the logic - no point being miserable for decades of your life in a less-than-ideal specialty to save yourself a bit of pain in the early years, and some sacrifices early on can lead to long-term gain.
But that only makes sense if there is a big difference in long-term payoff between specialties under consideration. For me, there doesn't seem to be one. Just as importantly, the next few years really matter to me - it's when I'd like to get married, buy a house, have kids. Trying to accomplish these life goals while in a time-intensive residency - or delaying them in order to finish residency - isn't a trade-off that seems worth it given the minimal differences in factors that matter to me between FM and Community Peds.
This is my long-winded way of saying I'm gunning for FM now. I don't have too many other question marks about other specialties - I either know I don't like them, or there's no compelling reason to prefer them over FM or Peds. Maybe I'll discover I hate FM when I rotate on it, but I've had decent exposure to the field so far and have generally enjoyed it, so I'm hopeful I won't be unpleasantly surprised. I'm a year away from having to make the final choice, but for the first time, it feels like I'm finally settling on a concrete option. That in itself is a huge stress reliever during the otherwise stressful time that is clerkship.
Thursday 26 November 2015
How Predictive Are Med School Exams?
It's been evaluation week on my clerkship block (don't worry, passed everything), and it brought up an interesting discussion - just how predictive are tests in evaluating students' likelihood to do well in practice? My block evaluations were quite fair, I certainly can't complain about them, but they did contain some odd elements that probably aren't too meaningful to future practice.
When we talk about testing in medicine, the sensitivity and specificity come up a lot. In medical education, those concepts could easily be applied - that is, how likely is it that a good future practitioner passes a given evaluation, and how likely is it that a bad future practitioner fails it? Outside of Quebec, Canadian medical schools use a pass/fail system with pass levels that are not particularly high. It's not too hard to pass the formal evaluations. And, in the event of an "off" day that results in a single failed evaluation, a repeat is typically granted without punishment provided it's not a regular occurrence (and you pass the repeat of course).
These tests are generally designed to identify unacceptably poor students and while individual tests might mistakenly call a good student inadequate, on the whole they're probably letting through students with trouble more so than they're failing otherwise good students. They have a high specificity, in other words - a true fail likely means the student has true issues to be addressed. They're probably not that sensitive though, so a pass doesn't mean much.
Predictive values of major tests have been studied in the past, but I've yet to see an analysis along the sensitivity/specificity lines. Mostly previous literature on the subject has demonstrated correlations, with the strongest correlations usually occurring between similar assessment tools (eg GPA correlates reasonably well with pre-clerkship grades, while MCAT correlates with the USMLE Step 1, but the correlation is weaker for other medical school metrics).
Anyway, not super useful right now, just another time to note that while we're busy developing evidence-based medicine, we're pretty far behind when it comes to evidenced-based medical education.
Sunday 22 November 2015
Continuity of Education
Continuity of care is an oft-discussed topic in medicine. Oversimplifying a bit, it means having the same provider or set of providers care for a single patient over time. The major upside is that the providers are fully aware of the patient's medical history and only need updates in between encounters rather than starting from scratch. Same goes for the relationship between patient and provider - rather than having to build it at each encounter, the relationship can be built and sustained over time. Implemented effectively, continuity of care should improve efficiency in medicine and quality of care.
The other facet of continuity of care is a seamless or near-seamless transition between various healthcare providers, when a transition is necessary. That is, providers should communicate well when referring patients between themselves and have a coherent plan for all aspects their care.
When it comes to education, continuity is equally important. We all have our challenges when learning a new task or skill, and medicine is no different. Overcoming those struggles is often a long-term prospect, requiring multiple different strategies before settling on an appropriate course of action. Having a single instructor or close-knit group of instructors can be enormously beneficial, as feedback can be given on new strategies with the results of previous efforts in mind. With a single instructor, a student's unique challenges, along with their strengths, don't have to be re-established at each encounter and can be incorporated into a plan for improvement moving forward. On an even more basic level, lessons can be tailored with full knowledge of gaps in previous lessons in mind.
Yet when it comes to medical education, particularly at the medical school level, continuity in education is virtually non-existent. In my third year of study, I have never been evaluated by a single person more than twice, other than maybe having the same person mark my exams (ie never an in-person evaluation, I'd just be a name to them, not a face). Where twice did happen, it was always in a single semester for a single class, typically only a few weeks or months apart. Never was there communication from one instructor to another on my strengths or weaknesses. It's a very fractured system.
If a student is generally doing well, this isn't too much of a concern - they'll pick up the little suggestions from each instructor and incorporate them as they move forward in their training. It's still not ideal, as more subtle problems often go unaddressed entirely and small issues can persist even if addressed, but the consequences aren't dire in these situations. For individuals who do struggle, lack of continuity can be a huge problem. Lack of progress isn't readily identifiable, since instructors only see a snapshot. Where progress is made, it generally goes unacknowledged - struggling students are either only recognized as being adequate (with little fanfare for the student's successful efforts), or inadequate (ignoring significant improvements the student may have made between evaluations).
In the worst situation, struggling students are passed without much feedback even if there are significant concerns. Most instructors are keen to help students improve, but they're also heavily incentivized to pass students along. When an instructor will likely never deal with a student again, they have no real reason to address problems. I see this way too often - when I ask for areas to improve upon, and I do at every evaluation, the most common answer is something along the lines of "not really, just keep doing what you're doing and reading". I'm a good student (I think), so I'm not expecting a litany of problems, but I do know that I'm far from perfect and that there are things I should be working on. I can easily see a struggling colleague getting the same treatment. When a student's problems do become too significant to ignore, it may be late in the game, in clerkship or later, and the realization of inadequacy can come without warning for the student. At this stage, opportunities for effective remediation are minimal, and high costs have already been borne by the student, who is now years into their training and tens of thousands of dollars in debt.
Medical education research has started to come to the conclusion that education isn't just the mechanical transmission of information from one person to another in the way a computer transmits data. Investment on the part of both the student and the instructor matters. As medical education evolves, we'll need to figure out a way to link students up with their evaluators over a longer period of time. A series of disconnected learning opportunities are simply not good enough to reliably ensure excellence in education, even if each individual educational event is of high quality. We need a higher focus on continuity in medical education.
The other facet of continuity of care is a seamless or near-seamless transition between various healthcare providers, when a transition is necessary. That is, providers should communicate well when referring patients between themselves and have a coherent plan for all aspects their care.
When it comes to education, continuity is equally important. We all have our challenges when learning a new task or skill, and medicine is no different. Overcoming those struggles is often a long-term prospect, requiring multiple different strategies before settling on an appropriate course of action. Having a single instructor or close-knit group of instructors can be enormously beneficial, as feedback can be given on new strategies with the results of previous efforts in mind. With a single instructor, a student's unique challenges, along with their strengths, don't have to be re-established at each encounter and can be incorporated into a plan for improvement moving forward. On an even more basic level, lessons can be tailored with full knowledge of gaps in previous lessons in mind.
Yet when it comes to medical education, particularly at the medical school level, continuity in education is virtually non-existent. In my third year of study, I have never been evaluated by a single person more than twice, other than maybe having the same person mark my exams (ie never an in-person evaluation, I'd just be a name to them, not a face). Where twice did happen, it was always in a single semester for a single class, typically only a few weeks or months apart. Never was there communication from one instructor to another on my strengths or weaknesses. It's a very fractured system.
If a student is generally doing well, this isn't too much of a concern - they'll pick up the little suggestions from each instructor and incorporate them as they move forward in their training. It's still not ideal, as more subtle problems often go unaddressed entirely and small issues can persist even if addressed, but the consequences aren't dire in these situations. For individuals who do struggle, lack of continuity can be a huge problem. Lack of progress isn't readily identifiable, since instructors only see a snapshot. Where progress is made, it generally goes unacknowledged - struggling students are either only recognized as being adequate (with little fanfare for the student's successful efforts), or inadequate (ignoring significant improvements the student may have made between evaluations).
In the worst situation, struggling students are passed without much feedback even if there are significant concerns. Most instructors are keen to help students improve, but they're also heavily incentivized to pass students along. When an instructor will likely never deal with a student again, they have no real reason to address problems. I see this way too often - when I ask for areas to improve upon, and I do at every evaluation, the most common answer is something along the lines of "not really, just keep doing what you're doing and reading". I'm a good student (I think), so I'm not expecting a litany of problems, but I do know that I'm far from perfect and that there are things I should be working on. I can easily see a struggling colleague getting the same treatment. When a student's problems do become too significant to ignore, it may be late in the game, in clerkship or later, and the realization of inadequacy can come without warning for the student. At this stage, opportunities for effective remediation are minimal, and high costs have already been borne by the student, who is now years into their training and tens of thousands of dollars in debt.
Medical education research has started to come to the conclusion that education isn't just the mechanical transmission of information from one person to another in the way a computer transmits data. Investment on the part of both the student and the instructor matters. As medical education evolves, we'll need to figure out a way to link students up with their evaluators over a longer period of time. A series of disconnected learning opportunities are simply not good enough to reliably ensure excellence in education, even if each individual educational event is of high quality. We need a higher focus on continuity in medical education.
Friday 20 November 2015
Syrian Refugees
Only tangentially related to medicine, but it's been in the news almost constantly and is a really good case study in the intricacies of actually helping others - and how intuition can undermine those efforts.
First and foremost, there's been an attitude floating around that Syrian refugees should be going to countries more similar to their ethnic, cultural, or socioeconomic backgrounds, particularly countries nearby. The thing is, they have. In massive numbers. The number of internally displaced Syrians is enormous, hundreds of thousands have moved within the country to avoid the conflict. Millions have relocated to nearby Turkey, Lebanon, and Jordan. A mere fraction of the approximately 4 million Syrian refugees have gone further than the Middle East, most to Europe. If Canada took even the 25,000 proposed refugees, it would represent a drop in the bucket compared to the number of total refugees. The proposals on the table don't represent Canada being enormously generous - we're mostly bickering about us barely doing our part to help refugees.
Perhaps more importantly, some of the need to relocate refugees to countries like Canada is a direct result of an unwillingness to be charitable beforehand. While hardly the only factor, a major contributor to Syrian refugees attempting to settle further away than Syria's neighbours is the horrible conditions in these refugee camps. Turkey, Lebanon and Jordan are not horribly poor countries, but they're not excessively rich either, and they have taken on a massive number of refugees. Lebanon, for example, has taken on at least 1.1 million Syrian refugees, in addition to another 500 thousand or so refugees from other countries (mostly Palestine), yet the number of actual Lebanese citizens is only about 4.1 million - over a quarter of the people in Lebanon are refugees! They needed (and still need) financial support to care for all these refugees properly and despite a mountain of promises from Western nations, that didn't come. If more Syrian refugees could have stayed in a reasonable state in the Middle East, we'd have less needing relocation. Western nations, insufficiently sensitive to the needs of these refugees, now find themselves in a penny-wise, pound-foolish state. Rather than cough of some money to support refugees close to their homes, they are faced with the prospect of higher costs to absorb refugees directly. Perhaps most ironically, the most vocal opponents of foreign aid are often the most vocal opponents of accepting new refugees, even though proper funding of foreign aid may have minimized the current refugee crisis, and potentially side-stepped the issue of accepting refugees in the first place. The Syrian refugee crisis is an odd case of self-defeating xenophobia.
Now, the past is the past - we can't now change the fact that there are thousands of Syrians who need a new home. Bringing some to Canada will undoubtedly help them, but could it hurt us? The Paris attacks have exposed lingering fears about the possibility of a terrorist attack in Canada, and that fear is being directed towards Syrian refugees. Unfortunately this is guilt by association. Heck, not even guilt by association, it's guilt by proxy. There's not much evidence that these refugees - or refugees in general - are at higher risk of committing violent acts, including terrorism. The Paris attackers were all EU nationals as far as we know, not refugees. Even if one or two come up as refugees, the majority will still be EU citizens. It's worth remembering that these people are running away from the very extremists Western citizens fear. While we're worried about being potential victims of extremism, these are actual victims of extremism. They deserve help.
Concerns about adequate screening have also come up frequently in the conversations I've heard/read. It's absolutely fair to want to take appropriate precautions against a Trojan Horse of some sort within the refugee population. However, no screening process will be 100% effective. Not only can good screens miss pertinent information or be fooled, but those who commit future attacks may have no plans to do so now. I have the dubious distinction of having amicably spent time with a terrorist, who eventually went on to be a suicide bomber. Of course we were in public school at the time, he wouldn't become radicalized for years after I knew him. But I never would have guessed he'd end up a terrorist and if any adults did at the time, there certainly wasn't any indication. Point is that background checks are only so effective and you can't just pick out a terrorist, even with extended close contact.
And that brings me to my last point. We often think of terrorists as fundamentally bad people. Certainly, anyone who commits atrocities like what happened in Paris has perpetrated a horrible crime and deserves punishment in accordance with the laws of a just society. Yet, terrorists aren't born evil, nor are they influenced solely by other evil people. They're affected by their circumstances, just as all of us are, and even good intentions can push people towards a bad path. My friend from public school - and at the time, I did consider him a friend - wasn't particularly malicious or cruel at the time. He could be a bit mean at times, but no more than any preteen. He did carry a lot of frustration though. Looking back, I can remember his fear, his anxiety, his anger. By the sounds of it, someone found an outlet for those emotions, and unfortunately it wasn't a positive one, which led him down the path towards terrorism. He had a lot of positive influences in his life too though. For my part, I hope I was one of those positive influences. But it wasn't enough, he got lost in the shuffle of life, and wound dead, far away from home, with his most notable impact on the world being cold-blooded murder.
Terrorists, as much as we hate to admit it, are just people, like you and me. Sometimes lost, sometimes confused, sometimes angry, misled, deceived, scared, or disturbed people, but still people.
And it is in this light we need to view Syrian refugees. They could become terrorists. Or they could become contributing member of society, including physicians - the number of immigrants to Canada who practice medicine is remarkably high. How we treat them will impact their future. Right now Western countries are sending a message that are not wanted, not deserving of help. To me, that can only build the fear, the frustration, the anger that I saw in my friend. By treating refugees with suspicion and distrust, we could easily create a self-fulfilling prophecy.
Yet we can also create the opposite self-fulfilling prophecy. If we accept these refugees with open arms, with compassion, we might find they're just as eager to help us as I hope we are to help them. We can keep trying to catch terrorists, foil terrorists, kill terrorists. Or we can try to stop terrorists from existing in the first place.
First and foremost, there's been an attitude floating around that Syrian refugees should be going to countries more similar to their ethnic, cultural, or socioeconomic backgrounds, particularly countries nearby. The thing is, they have. In massive numbers. The number of internally displaced Syrians is enormous, hundreds of thousands have moved within the country to avoid the conflict. Millions have relocated to nearby Turkey, Lebanon, and Jordan. A mere fraction of the approximately 4 million Syrian refugees have gone further than the Middle East, most to Europe. If Canada took even the 25,000 proposed refugees, it would represent a drop in the bucket compared to the number of total refugees. The proposals on the table don't represent Canada being enormously generous - we're mostly bickering about us barely doing our part to help refugees.
Perhaps more importantly, some of the need to relocate refugees to countries like Canada is a direct result of an unwillingness to be charitable beforehand. While hardly the only factor, a major contributor to Syrian refugees attempting to settle further away than Syria's neighbours is the horrible conditions in these refugee camps. Turkey, Lebanon and Jordan are not horribly poor countries, but they're not excessively rich either, and they have taken on a massive number of refugees. Lebanon, for example, has taken on at least 1.1 million Syrian refugees, in addition to another 500 thousand or so refugees from other countries (mostly Palestine), yet the number of actual Lebanese citizens is only about 4.1 million - over a quarter of the people in Lebanon are refugees! They needed (and still need) financial support to care for all these refugees properly and despite a mountain of promises from Western nations, that didn't come. If more Syrian refugees could have stayed in a reasonable state in the Middle East, we'd have less needing relocation. Western nations, insufficiently sensitive to the needs of these refugees, now find themselves in a penny-wise, pound-foolish state. Rather than cough of some money to support refugees close to their homes, they are faced with the prospect of higher costs to absorb refugees directly. Perhaps most ironically, the most vocal opponents of foreign aid are often the most vocal opponents of accepting new refugees, even though proper funding of foreign aid may have minimized the current refugee crisis, and potentially side-stepped the issue of accepting refugees in the first place. The Syrian refugee crisis is an odd case of self-defeating xenophobia.
Now, the past is the past - we can't now change the fact that there are thousands of Syrians who need a new home. Bringing some to Canada will undoubtedly help them, but could it hurt us? The Paris attacks have exposed lingering fears about the possibility of a terrorist attack in Canada, and that fear is being directed towards Syrian refugees. Unfortunately this is guilt by association. Heck, not even guilt by association, it's guilt by proxy. There's not much evidence that these refugees - or refugees in general - are at higher risk of committing violent acts, including terrorism. The Paris attackers were all EU nationals as far as we know, not refugees. Even if one or two come up as refugees, the majority will still be EU citizens. It's worth remembering that these people are running away from the very extremists Western citizens fear. While we're worried about being potential victims of extremism, these are actual victims of extremism. They deserve help.
Concerns about adequate screening have also come up frequently in the conversations I've heard/read. It's absolutely fair to want to take appropriate precautions against a Trojan Horse of some sort within the refugee population. However, no screening process will be 100% effective. Not only can good screens miss pertinent information or be fooled, but those who commit future attacks may have no plans to do so now. I have the dubious distinction of having amicably spent time with a terrorist, who eventually went on to be a suicide bomber. Of course we were in public school at the time, he wouldn't become radicalized for years after I knew him. But I never would have guessed he'd end up a terrorist and if any adults did at the time, there certainly wasn't any indication. Point is that background checks are only so effective and you can't just pick out a terrorist, even with extended close contact.
And that brings me to my last point. We often think of terrorists as fundamentally bad people. Certainly, anyone who commits atrocities like what happened in Paris has perpetrated a horrible crime and deserves punishment in accordance with the laws of a just society. Yet, terrorists aren't born evil, nor are they influenced solely by other evil people. They're affected by their circumstances, just as all of us are, and even good intentions can push people towards a bad path. My friend from public school - and at the time, I did consider him a friend - wasn't particularly malicious or cruel at the time. He could be a bit mean at times, but no more than any preteen. He did carry a lot of frustration though. Looking back, I can remember his fear, his anxiety, his anger. By the sounds of it, someone found an outlet for those emotions, and unfortunately it wasn't a positive one, which led him down the path towards terrorism. He had a lot of positive influences in his life too though. For my part, I hope I was one of those positive influences. But it wasn't enough, he got lost in the shuffle of life, and wound dead, far away from home, with his most notable impact on the world being cold-blooded murder.
Terrorists, as much as we hate to admit it, are just people, like you and me. Sometimes lost, sometimes confused, sometimes angry, misled, deceived, scared, or disturbed people, but still people.
And it is in this light we need to view Syrian refugees. They could become terrorists. Or they could become contributing member of society, including physicians - the number of immigrants to Canada who practice medicine is remarkably high. How we treat them will impact their future. Right now Western countries are sending a message that are not wanted, not deserving of help. To me, that can only build the fear, the frustration, the anger that I saw in my friend. By treating refugees with suspicion and distrust, we could easily create a self-fulfilling prophecy.
Yet we can also create the opposite self-fulfilling prophecy. If we accept these refugees with open arms, with compassion, we might find they're just as eager to help us as I hope we are to help them. We can keep trying to catch terrorists, foil terrorists, kill terrorists. Or we can try to stop terrorists from existing in the first place.
Tuesday 17 November 2015
Likes and Dislikes in Pediatrics
My second rotation of clerkship has been Peds. I'm getting closer to the end of it, so I thought I'd continue with what I started with my OBGYN and mention a few things I've learned on the rotation. Peds I wanted to have early in my clerkship because it was fairly high on my list of potential specialties to pursue for residency, but I hadn't had much clinical exposure in the field. It's been a good rotation to clarify my clinical interests.
Here are my take-aways thus far from Peds:
1) Kids are awesome
I like working with kids, of all ages and states of health. They're interesting to talk to, fun to examine (tickling as a distraction technique just doesn't work as well in adults), and you never quite know what you're going to get meeting a new pediatric patient. The social aspect is trickier, and parents can hinder care as much as help it, but most are good and I enjoy working with even the most troublesome parents. I know a lot of physicians view parents as an annoyance, I tend to see them as just another patient in need of care. A lot of pediatrics is about caring for the family as a whole, not just the sick child, and I really like that type of comprehensive family care (though in practice, it often falls short of where it ideally should be).
2) Not a big fan of inpatient medicine
I'm increasingly realizing that I don't like working in a hospital, especially on an inpatient floor. A lot of time is spent working around the patient rather than working with them, typically involving talking to other doctors. The patient or their family may or may not be fully in the loop. Interactions with each individual patient are infrequent, a few times a day at most, oftentimes much less. I find this problematic, especially considering the disruptive nature of hospitalizations to a person's life. Too often patients do not grasp why they're there, what they're doing that day, or even who everyone is caring for them. The medical aspects of inpatient care are quite interesting and it's a good learning opportunity. However, that tends to lead to good treatments, but overall care that is often rather poor or fragmented.
Inpatient medicine is also quite detail-oriented, but the importance of those details is not always clear. As I said, a lot of time is spent with doctors talking to other doctors, usually about these details. Yet, there are rarely consistent opinions in these discussions - talk to 5 different physicians you'll get 5 different viewpoints. To me, that means either inpatient medicine frequently gets things wrong depending on which physician's opinion wins out, or it doesn't matter which opinion you take and the details probably don't matter much. I lean towards the latter and I don't get particularly excited about spending most of my time quibbling about minutiae.
I enjoy big-picture problems and patient contact. Inpatient medicine doesn't seem have enough of either for my liking.
3) Infectious diseases everywhere
I got sick this rotation. A lot. With not-so-fun illnesses. Had to take only a small amount of time off, but it ate up what few breaks I got. The residents seem to have built up more of an immunity to the common bugs, but for a first-timer working with truly sick kids, I got hit pretty hard. It's really hard to work - especially on overnight call shifts - when you're not anywhere close to 100% health-wise. I said before that long hours aren't a good fit for me and I'd rather go for specialties that have fewer hours or allow for part-time work. Having the opportunity to take time off when sick would also be a huge plus.
4) The happiness test
Taking to heart the advice "Go where the happy people are", I'm keeping a close eye on how happy the people on each rotation seem to be. Pediatricians are definitely happy people. Some are a bit more reserved, some are definitely tired (residents far more than staff) and I have met the odd unpleasant physician on this rotation, but the average pediatrician is actively smiling.
Every specialty will have some very satisfied practitioners, as well as some downright miserable ones, but where the typical physician in that specialty falls is telling me a lot about the fields of work. In OBGYN, the typical resident or staff appeared exhausted but mostly contented. In Pediatrics, the typical resident or staff appears almost joyous, with maybe a hint of fatigue. Both are largely positive states of being, but the difference is evident.
Overall, Peds is still pretty high on my list of specialties to match to, but it's slipped a bit. I had thought about doing Community Peds or Peds Emerg and those both still seem like attractive options, but it would take 3+ years of largely inpatient pediatrics to get there. I'm not sure that's a worthwhile trade-off when Family Medicine is on the table, with its similar compensation to Peds, a much better job market, shorter residencies with a focus on outpatient medicine, and much more flexibility in terms of location or practice arrangement. I like working with kids, but I also find I like working with adults. The main reason to go into Peds would be to cut out the older people from my practice, so if I don't want to do that (or I'm indifferent to it), what's the point? Won't take long to be sure where I stand though - my Internal Medicine rotation is coming up next!
Here are my take-aways thus far from Peds:
1) Kids are awesome
I like working with kids, of all ages and states of health. They're interesting to talk to, fun to examine (tickling as a distraction technique just doesn't work as well in adults), and you never quite know what you're going to get meeting a new pediatric patient. The social aspect is trickier, and parents can hinder care as much as help it, but most are good and I enjoy working with even the most troublesome parents. I know a lot of physicians view parents as an annoyance, I tend to see them as just another patient in need of care. A lot of pediatrics is about caring for the family as a whole, not just the sick child, and I really like that type of comprehensive family care (though in practice, it often falls short of where it ideally should be).
2) Not a big fan of inpatient medicine
I'm increasingly realizing that I don't like working in a hospital, especially on an inpatient floor. A lot of time is spent working around the patient rather than working with them, typically involving talking to other doctors. The patient or their family may or may not be fully in the loop. Interactions with each individual patient are infrequent, a few times a day at most, oftentimes much less. I find this problematic, especially considering the disruptive nature of hospitalizations to a person's life. Too often patients do not grasp why they're there, what they're doing that day, or even who everyone is caring for them. The medical aspects of inpatient care are quite interesting and it's a good learning opportunity. However, that tends to lead to good treatments, but overall care that is often rather poor or fragmented.
Inpatient medicine is also quite detail-oriented, but the importance of those details is not always clear. As I said, a lot of time is spent with doctors talking to other doctors, usually about these details. Yet, there are rarely consistent opinions in these discussions - talk to 5 different physicians you'll get 5 different viewpoints. To me, that means either inpatient medicine frequently gets things wrong depending on which physician's opinion wins out, or it doesn't matter which opinion you take and the details probably don't matter much. I lean towards the latter and I don't get particularly excited about spending most of my time quibbling about minutiae.
I enjoy big-picture problems and patient contact. Inpatient medicine doesn't seem have enough of either for my liking.
3) Infectious diseases everywhere
I got sick this rotation. A lot. With not-so-fun illnesses. Had to take only a small amount of time off, but it ate up what few breaks I got. The residents seem to have built up more of an immunity to the common bugs, but for a first-timer working with truly sick kids, I got hit pretty hard. It's really hard to work - especially on overnight call shifts - when you're not anywhere close to 100% health-wise. I said before that long hours aren't a good fit for me and I'd rather go for specialties that have fewer hours or allow for part-time work. Having the opportunity to take time off when sick would also be a huge plus.
4) The happiness test
Taking to heart the advice "Go where the happy people are", I'm keeping a close eye on how happy the people on each rotation seem to be. Pediatricians are definitely happy people. Some are a bit more reserved, some are definitely tired (residents far more than staff) and I have met the odd unpleasant physician on this rotation, but the average pediatrician is actively smiling.
Every specialty will have some very satisfied practitioners, as well as some downright miserable ones, but where the typical physician in that specialty falls is telling me a lot about the fields of work. In OBGYN, the typical resident or staff appeared exhausted but mostly contented. In Pediatrics, the typical resident or staff appears almost joyous, with maybe a hint of fatigue. Both are largely positive states of being, but the difference is evident.
Overall, Peds is still pretty high on my list of specialties to match to, but it's slipped a bit. I had thought about doing Community Peds or Peds Emerg and those both still seem like attractive options, but it would take 3+ years of largely inpatient pediatrics to get there. I'm not sure that's a worthwhile trade-off when Family Medicine is on the table, with its similar compensation to Peds, a much better job market, shorter residencies with a focus on outpatient medicine, and much more flexibility in terms of location or practice arrangement. I like working with kids, but I also find I like working with adults. The main reason to go into Peds would be to cut out the older people from my practice, so if I don't want to do that (or I'm indifferent to it), what's the point? Won't take long to be sure where I stand though - my Internal Medicine rotation is coming up next!
Saturday 14 November 2015
Priorities
I've worked with kids a lot, particularly before medical school. One kid, I'll never forget, had parents who were very interested in where he went to school, fighting rather hard to get him enrolled and transported to a particular school that they believed would give him the best education. They were adamant and dedicated to this goal.
And they were under investigation by child protective services, with the very real possibility of having their children taken away. Wait, what? Despite these parents' strong desire to have their child at what they believed to be a good school, these parents were neglectful, failing to provide adequate nutrition, as well as poor social, emotional, and structural support for their children. The kid I worked with spent so much time looking after their siblings, they never got a chance to be a kid. These parents weren't opposed to feeding their children, or providing the other necessities of life, but their priorities were completely out of whack. They'd fight for their children to go to a desirable school, which is an admirable thing for parents to do, but it's far less important than putting food on the table. The parents weren't overtly abusive, and had some good intentions, but they were nevertheless neglectful, and that had a huge negative impact on their children.
I bring up this story because I've been struggling a lot with priorities. Clerkship has made it absolutely clear that there are some deep problems in the way we treat patients, and in the way we educate physicians. Yet I've rarely seen too many clear instances of wrong-doing. I've heard stories of physicians who were dismissive or disdainful of patients. Others, who were verbally or physically abusive of students or residents. I've seen or experienced only minor instances of these abuses. Most physicians want the best for their patients and want students to have a good experience, as do most of the other staff responsible for patient care and student education.
However, I've still felt as though the healthcare system has been frequently failing to care for patients, and the education system has frequently failed to properly support students. Given the positive intentions and actions of the majority of the individual actors involved in these systems, I chock these failings up to neglect. And, just as the parents in my story were neglectful because their priorities were in the wrong places, so too does the healthcare system engage in routine neglect of patients due to misplaced priorities. Likewise, the education system frequently neglects the needs of students due to its priorities.
Let me give an example for each. In many departments in the hospital, the main interaction physician teams have with their patients is during morning rounds. Rounds are often fast - 15 minutes per patient - and may not include the whole team. The team itself can change frequently. It's not uncommon for a single patient to see multiple different physicians, residents, or students in the course of their care. Afterwards, the team of physicians may never see the patient again that day, hearing of new concerns or changes in their status only through nurses' reports. Yet, this team will be the ones making decisions on the patient's care, going beyond those 15 minutes of interaction per day only as necessary. Each provider is often courteous and caring during those 15 minutes, but for a sick patient, 15 minutes a day interacting with the people who are most responsible for their care isn't really enough to feel cared for or heard. This is particularly true when these physicians/residents/students are in a rush to finish, as they often are - other patients, mandatory teaching, meetings, and supplementary tasks all take priority to spending extra time with each patient. As much as physicians and trainees want to be present and provide full care for their patients, it is so low on the priority list that it is often neglected.
Same goes for medical education with respect to students. Physician educators care about the well-being of their students. However, when put up against training and testing, it falls in priority. This is how we get incredibly long work weeks for students (and burned out, exhausted students). While medical educators would rather have rested learners, when put up against getting extra hours of hospital time, it simply isn't a priority.
In each case, it's not as though the current priorities are inappropriate goals. In an ideal world, physicians would care for large numbers of patients, while participating in continuing education, meetings, etc. Students having a wealth of experience an admirable goal. Yet, is physician efficiency more important than those physicians spending sufficient time with each patient? Is another 10 hours a week in the hospital more important than learners having time to explore their own interests, spend time with the world outside of medicine, or simply to sleep? I would argue no.
Changing priorities comes with trade-offs, of that I am fully aware. Physicians spending more time with patients may mean more physicians overall and less pay for each. Less time per week in hospital for students may mean a reduction in knowledge at graduation (though studies on that subject are lacking/equivocal). Yet, if we want physicians to put the priority on the care of their patients, or schools on the overall well-being and success of their students, it's going to take embracing or adapting to these trade-offs. The mission statements of hospitals and medical schools often feature these priorities prominently - it's time for them to walk the walk, rather than simply talk the talk.
And they were under investigation by child protective services, with the very real possibility of having their children taken away. Wait, what? Despite these parents' strong desire to have their child at what they believed to be a good school, these parents were neglectful, failing to provide adequate nutrition, as well as poor social, emotional, and structural support for their children. The kid I worked with spent so much time looking after their siblings, they never got a chance to be a kid. These parents weren't opposed to feeding their children, or providing the other necessities of life, but their priorities were completely out of whack. They'd fight for their children to go to a desirable school, which is an admirable thing for parents to do, but it's far less important than putting food on the table. The parents weren't overtly abusive, and had some good intentions, but they were nevertheless neglectful, and that had a huge negative impact on their children.
I bring up this story because I've been struggling a lot with priorities. Clerkship has made it absolutely clear that there are some deep problems in the way we treat patients, and in the way we educate physicians. Yet I've rarely seen too many clear instances of wrong-doing. I've heard stories of physicians who were dismissive or disdainful of patients. Others, who were verbally or physically abusive of students or residents. I've seen or experienced only minor instances of these abuses. Most physicians want the best for their patients and want students to have a good experience, as do most of the other staff responsible for patient care and student education.
However, I've still felt as though the healthcare system has been frequently failing to care for patients, and the education system has frequently failed to properly support students. Given the positive intentions and actions of the majority of the individual actors involved in these systems, I chock these failings up to neglect. And, just as the parents in my story were neglectful because their priorities were in the wrong places, so too does the healthcare system engage in routine neglect of patients due to misplaced priorities. Likewise, the education system frequently neglects the needs of students due to its priorities.
Let me give an example for each. In many departments in the hospital, the main interaction physician teams have with their patients is during morning rounds. Rounds are often fast - 15 minutes per patient - and may not include the whole team. The team itself can change frequently. It's not uncommon for a single patient to see multiple different physicians, residents, or students in the course of their care. Afterwards, the team of physicians may never see the patient again that day, hearing of new concerns or changes in their status only through nurses' reports. Yet, this team will be the ones making decisions on the patient's care, going beyond those 15 minutes of interaction per day only as necessary. Each provider is often courteous and caring during those 15 minutes, but for a sick patient, 15 minutes a day interacting with the people who are most responsible for their care isn't really enough to feel cared for or heard. This is particularly true when these physicians/residents/students are in a rush to finish, as they often are - other patients, mandatory teaching, meetings, and supplementary tasks all take priority to spending extra time with each patient. As much as physicians and trainees want to be present and provide full care for their patients, it is so low on the priority list that it is often neglected.
Same goes for medical education with respect to students. Physician educators care about the well-being of their students. However, when put up against training and testing, it falls in priority. This is how we get incredibly long work weeks for students (and burned out, exhausted students). While medical educators would rather have rested learners, when put up against getting extra hours of hospital time, it simply isn't a priority.
In each case, it's not as though the current priorities are inappropriate goals. In an ideal world, physicians would care for large numbers of patients, while participating in continuing education, meetings, etc. Students having a wealth of experience an admirable goal. Yet, is physician efficiency more important than those physicians spending sufficient time with each patient? Is another 10 hours a week in the hospital more important than learners having time to explore their own interests, spend time with the world outside of medicine, or simply to sleep? I would argue no.
Changing priorities comes with trade-offs, of that I am fully aware. Physicians spending more time with patients may mean more physicians overall and less pay for each. Less time per week in hospital for students may mean a reduction in knowledge at graduation (though studies on that subject are lacking/equivocal). Yet, if we want physicians to put the priority on the care of their patients, or schools on the overall well-being and success of their students, it's going to take embracing or adapting to these trade-offs. The mission statements of hospitals and medical schools often feature these priorities prominently - it's time for them to walk the walk, rather than simply talk the talk.
Monday 9 November 2015
Sick
Caught a stomach bug a few days ago. Not fun at all. Watery stuff coming out of everywhere. Fortunately it doesn't last long and I'm already on the mend.
First time I've had a true stomach flu though, so it's been an interesting learning experience. Had almost a textbook progression of the disease, which has made it almost comically easy to remember the timeline of a stomach virus infection - I just have to remember when my symptoms started up and when they left, which isn't that hard when many of those symptoms are physically horrifying. Not that I'm advocating med students all go out and get every infectious disease they can, but it's a good reminder that nothing teaches like first-hand experience!
First time I've had a true stomach flu though, so it's been an interesting learning experience. Had almost a textbook progression of the disease, which has made it almost comically easy to remember the timeline of a stomach virus infection - I just have to remember when my symptoms started up and when they left, which isn't that hard when many of those symptoms are physically horrifying. Not that I'm advocating med students all go out and get every infectious disease they can, but it's a good reminder that nothing teaches like first-hand experience!
Passion in Medical Education
Had a "bonus" teaching session the other day. Well, technically it was mandatory, but it wasn't part of the official curriculum and I don't think there were any consequences for missing it, so exactly how mandatory it was is questionable.
Anyway, it was pretty clear this was an initiative started by the instructor, not the school, to cover a clear hole in our official training. It was a fairly simple lesson, but very well taught and extremely high-yield. I got to put the lesson into practice mere hours later, to great effect.
I've noticed a lot of my best learning opportunities come outside the standard curriculum. Sometimes these are initiated in conjunction with the school, sometimes not, but they're always driven primarily by the instructors themselves. Looking back, most of my more enduring learning has come through these extra-curricular sources. There are some facts that just float around in your head and some that are practically burned in there and for me, pretty much all of the latter come from these informal sessions.
The classic approach to education is to set requirements for lectures and other educational activities, then to test to ensure the information has been passed on (as well as to promote self-study on the part of learners). This works reasonably well to ensure a minimal set of knowledge is acquired, but it's rather inefficient and not all that effective. The main problem is the classic approach relies almost solely on extrinsic motivation of students - using either rewards or punishments for doing well or doing poorly along whatever evaluation metric is employed. That encourages a lot of short-term learning, cramming, or strict adherence to what is being taught. In an expansive, evolving, and applied field like medicine, that's a recipe for inefficiency. Important information may not be emphasized sufficiently in the curriculum, may not be well-tailored to a student's eventual practice, and even if a student does well on a test or other exam, that knowledge may not be well retained in the future.
Extrinsic motivation is also at play when it comes to educators. I can't say how many times I've had a lecturer say "I've been asked to talk about this subject, so here goes..." Sometimes that works out and quality instruction is given. Sometimes the instructor knows their topic well, but isn't a great teacher, or doesn't understand the broader context of our education, and their lesson is rather low-yield. Sometimes the instructor is fine as a teacher, but they aren't an expert on their subject and are just doing the best they can. Schools use the carrot and the stick on their faculty members just as much as they do on students, with much the same drawbacks.
When an instructor goes out of their way to host a session, they are always an expert on the subject, they're generally good teachers, and the information they give is generally quite applicable in practice. Likewise, when a student goes out of their way to attend a session, they are almost always interested, attentive, and receptive. It only makes sense that I would have my best learning experiences in these situations - both I and the instructor were invested in me acquiring that knowledge. These activities draw on intrinsic motivation to learn, which is rather strong in most people, but I would argue is exceptionally strong in medical students and physicians who generally spend their whole lives in search of new knowledge.
The challenge with medical education - with all education - is how to rely more heavily on intrinsic motivation to learn while maintaining standards. After all, the reason extrinsic motivation is necessary at all is that all of us have some important aspects of medicine we're not horribly interested in, yet have to learn anyway. I think a major part of medical education would be to bring some more choice into play for both students and instructors, using the more heavy-handed approaches like mandatory sessions or high-impact testing only for the sheer basics. For the vast majority of medicine though, a bit more choice and flexibility - for students and instructors - could be a very positive thing. Sure, there'll be cracks in their learning without a centralized curriculum, but frankly, centralized curriculums have plenty of cracks anyway. An intrinsically motivated student, with enough time and energy, will have no problem filling those cracks in - an extrinsically motivated student has no such incentive.
Anyway, it was pretty clear this was an initiative started by the instructor, not the school, to cover a clear hole in our official training. It was a fairly simple lesson, but very well taught and extremely high-yield. I got to put the lesson into practice mere hours later, to great effect.
I've noticed a lot of my best learning opportunities come outside the standard curriculum. Sometimes these are initiated in conjunction with the school, sometimes not, but they're always driven primarily by the instructors themselves. Looking back, most of my more enduring learning has come through these extra-curricular sources. There are some facts that just float around in your head and some that are practically burned in there and for me, pretty much all of the latter come from these informal sessions.
The classic approach to education is to set requirements for lectures and other educational activities, then to test to ensure the information has been passed on (as well as to promote self-study on the part of learners). This works reasonably well to ensure a minimal set of knowledge is acquired, but it's rather inefficient and not all that effective. The main problem is the classic approach relies almost solely on extrinsic motivation of students - using either rewards or punishments for doing well or doing poorly along whatever evaluation metric is employed. That encourages a lot of short-term learning, cramming, or strict adherence to what is being taught. In an expansive, evolving, and applied field like medicine, that's a recipe for inefficiency. Important information may not be emphasized sufficiently in the curriculum, may not be well-tailored to a student's eventual practice, and even if a student does well on a test or other exam, that knowledge may not be well retained in the future.
Extrinsic motivation is also at play when it comes to educators. I can't say how many times I've had a lecturer say "I've been asked to talk about this subject, so here goes..." Sometimes that works out and quality instruction is given. Sometimes the instructor knows their topic well, but isn't a great teacher, or doesn't understand the broader context of our education, and their lesson is rather low-yield. Sometimes the instructor is fine as a teacher, but they aren't an expert on their subject and are just doing the best they can. Schools use the carrot and the stick on their faculty members just as much as they do on students, with much the same drawbacks.
When an instructor goes out of their way to host a session, they are always an expert on the subject, they're generally good teachers, and the information they give is generally quite applicable in practice. Likewise, when a student goes out of their way to attend a session, they are almost always interested, attentive, and receptive. It only makes sense that I would have my best learning experiences in these situations - both I and the instructor were invested in me acquiring that knowledge. These activities draw on intrinsic motivation to learn, which is rather strong in most people, but I would argue is exceptionally strong in medical students and physicians who generally spend their whole lives in search of new knowledge.
The challenge with medical education - with all education - is how to rely more heavily on intrinsic motivation to learn while maintaining standards. After all, the reason extrinsic motivation is necessary at all is that all of us have some important aspects of medicine we're not horribly interested in, yet have to learn anyway. I think a major part of medical education would be to bring some more choice into play for both students and instructors, using the more heavy-handed approaches like mandatory sessions or high-impact testing only for the sheer basics. For the vast majority of medicine though, a bit more choice and flexibility - for students and instructors - could be a very positive thing. Sure, there'll be cracks in their learning without a centralized curriculum, but frankly, centralized curriculums have plenty of cracks anyway. An intrinsically motivated student, with enough time and energy, will have no problem filling those cracks in - an extrinsically motivated student has no such incentive.
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