Just a quick post to wish anyone reading a happy holidays. Hope everyone who celebrates it had a good Christmas yesterday and hope that everyone who buys things is enjoying the Boxing Day sales today.
I got an interesting stocking-stuffer gift this year, a pocket medical dictionary from 1928. It's an interesting read! Lots of terms that are no longer in use or which have changed in use in the past century. There's a big focus on herbalism and infectious diseases, since Penicillin was only invented that very year and wasn't used clinically for over a decade afterwards. Heck, there's an entry for Penicillium, the fungus that produces Penicillin, but not the drug itself!
There are also a lot of subtly (or not-so-subtly) racist terms... not cool old docs, not cool.
Anyway, it's a fun distraction. Shows how far medicine has come in many respects, but also how much has remained the same. A lot of the terms used exclusively in medicine today are unchanged from a century ago, particularly the anatomical terms. I've got a physics background, so I'm used to learning about discoveries from centuries ago, but medicine we often think about as a more modern creation. My fancy old-school medical dictionary is a nice reminder that all we know has been developed over a very long period of time, a knowledge base built by a very large number of people.
Saturday 26 December 2015
Monday 21 December 2015
Documentation
I requested a rotation away from my home school for my FM block, one that I'm really excited about. Unfortunately, I've just been informed that I have to submit a giant heaping pile of documentation about my immunization status. Now, I've had to submit all this stuff to my home school already. I've had to submit it to the hospital three times. I had to submit it to my undergrad school too, plus at least two volunteer groups. At some point along the line, can't it be assumed that either I'm immune to the things they want me to be immune to, or at least I'm so good at faking it that I'll fool them too?
They don't just want the documentation either - they want a physician or nurse to sign off on it. Exactly what a physician or nurse can do to look at my documentation that anyone with eyes can't, I have no idea, but it's required, so I have to do it.
Worst, I don't know where my N95 mask certification went. I think it got automatically submitted to my home school and I have to go through them to get it, but I may have just lost it, which means I'll have to repeat the testing since my previous was slightly over 2 years old. Nevermind that I've been tested at least 4 times, each time getting fitted with the 1870 mask. Nevermind that I've never had to use an N95 mask and am starting on a rotation where the likelihood of me needing one or even being in a facility with a variety of N95 masks on hand is slim-to-none. Nevermind that if I do need to wear one, since I don't shave every day - and am not required to - the small amount of stubble I'm likely to have would break the seal. Nope, if I can't find that piece of paper that confirms what another piece of paper from 2 years ago said, I'll have to go through the testing process all over again.
Just a great use of my time, the doctor or nurse's time I'll have to take up, and healthcare/medical education dollars in general.
Anyway, it'll get done. I had to get a lot of this stuff together anyway for electives in the fall, but it was a bit shocking to be rushed into it on my first day on vacation...
Saturday 19 December 2015
Vacation Time
During clerkship at my school, we get a grand total of 3 weeks off during the year and no, we don't get to set when they are. Today I start my first week of vacation! Unless you count the time I was sick and on the floor with stomach flu (and I don't) this is the first time in 4 months I'm even getting a full 72 hours away from the hospital.
And wow, did I need a break. I've worked far longer than 4 months straight before without much difficulty before, but there's a huge difference between working 40 hours a week with weekends off, (or being in school 25 hours a week with an extra 30 for studying/ECs set on your schedule), and working 60 hours a week, including nights and weekends regularly, with another 15 devoted to studying/ECs, all mostly out of your control to schedule. I'm tired. I've probably had 4 weeks in the last 4 months where I wasn't chronically tired, and only a few days where I felt truly rested.
I thought I'd take this opportunity to go through some of my fatigue-coping strategies. None of these are overly unique, most of them have an evidence base behind them, but I think they're worth highlighting.
#1) Make Time For Sleep
The average person should sleep 50-55 hours a week, ideally on a regular schedule. Some people can get away with less, maybe 45 or even 40 hours on the low end, but less than that generally means chronic sleep deprivation. I need sleep on the higher end of the spectrum - if I start dropping below 50 hours of sleep in week, I'm exhausted.
So I put the emphasis on sleep. If I'm tired, I try to go to bed an hour or half-an-hour early. I set my alarm as late as I can get away with. If I have a choice between getting an extra hour of studying and an extra hour of sleep, I choose sleep.
I know classmates who don't make this choice, and you can see the fatigue. Maybe they handle fatigue better than I do, most are a few years younger than me, but I can't imagine the difference is that great. Chronic fatigue makes us worse students and worse physicians-in-training, so I make time for sleep.
#2) Exercise!
The benefits of exercise as numerous and its effects on fatigue and alertness are well-established. It's tough to get enough exercise when you're lacking time and are already low-energy, but it's important to remember that exercise is an energy investment - you give up some energy now for more energy overall.
I walk to work. I walk from work. I walk the dog at least once a day, often twice, and I have a big, active dog. I take stairs in the hospital when I can. It all adds up to a good amount of activity.
Nevertheless, that's probably not enough. I should be getting more moderate- or high-intensity exercise on a regular basis. In contrast to my sleeping patterns, I know classmates who do a much better job of prioritizing exercise than I do. I should really be hitting the gym. This is on my to-do list of things to work on moving forward.
#3) Taking Little Breaks
There's no time in clerkship for long breaks, especially if you have obligations at home. Even an hour away from any responsibilities is hard to get on a regular basis. That's where small, 5 to 15 minute breaks can be a huge help. The key is to make it a true break - to get away from all stressors and to let your mind rest or work through whatever it needs to work through. Sometimes that's taking 15 minutes before bed to just process what happened during the day. Sometimes that's taking 5 minutes in the morning to relax and just have a clear head for the coming day.
Like most people, I use music to help take a quick break. Music, especially familiar music, is naturally calming (even if it's high-intensity music) and helps screen out other distractions without taxing your brain. I tend to draw on a small number of songs that I listen to ad nauseam. My go-to song is Matthew Good's Sort of a Protest Song:
Besides just being a good song with a relatively calming melody, I listen to it because its theme generally matches my mood when I need a quick break. Between the lyrics and what has to be my favourite title for any song, it expresses my sentiments all too well - that I'm tired from being "on" for too long, it sucks, I don't like it, I'd really like to stop, but I have to keep going and I know it.
Alright, not just that I have to keep going, but I want to keep going. As much as I complain about medical school, that I definitely don't want to do what I'm currently doing for the rest of my life, and that I'm incredibly frustrated by so many aspects of my medical training right now, I want to see this through to the end. I still value the end goal and would hate myself if I gave up.
So, I take 6 minutes to listen to Matt Good and have my little non-protest protest against my current situation. And then I put my jacket on and head out the door, just a little bit more rested.
Tuesday 15 December 2015
It's Alright to Hate Medical School
Stumbled across these two blog posts which present a wonderful contrast of opinions on views of medical school. I encourage anyone reading this post to read those two, but then to pay particular attention to the comments; they're just as revealing as the posts themselves. Some people love their time in medical school, approaching every aspect with unbridled enthusiasm. Some people hate their time in medical school, grudgingly dragging themselves through every aspect.
Of course most people fall somewhere into the middle with a lean towards one side or the other, but I there are more than a few people decidedly on one end or the other.
I'm definitely in the latter category. Ok, I don't hate medical school, certainly not 100% of the time, but I'm frustrated with my experiences in medical school far more often than I've been happy or even satisfied with them. The second post linked almost perfectly explains why I feel this way: I got into medicine to connect with people in a meaningful way and, ideally, to have lasting, positive impact on their health and/or lives in general. Yet, medical school more often than not pushes me in the opposite direction.
Meaningful contact with other people - even simple human interaction like normal people do each and every day - is secondary and often discouraged. Much of the health care system, including a good portion under the control of physicians, does not seem designed to provide adequate care, let alone excellent care. As the lowest person on the totem pole, you have no choice but to go along with what I consider substandard or fractured care. I can hate it all I want, but not only do I have to put up with this system, I have to advance and at times defend that system.
Let me be clear - the care is substandard, but the medicine is usually (though not always) fine. And that gets to the heart of the divide in viewpoints on medical school. For me, medicine is the means to an end. I want to help people, but don't particularly care how as long as it's effective. Good medical care can have an incredibly beneficial effect on a person's life, but getting the medicine right is only the first step in getting good care. It's necessary, but not sufficient.
Yet for some physicians or physicians-to-be, the medicine isn't means to an end, it's an end itself. For those who love the medicine, I imagine medical school is great, it's very much focused on acquiring and refining medical knowledge. For those of us who are very much patient-focused, learning about the medicine at the expense of forgetting about the patients is not a worthwhile trade-off, even if it is (hopefully) a temporary one.
This is not to suggest that people who love medical school are not going to care about their patients. It's a spectrum - some people who love the medicine are keenly devoted to the well-being of their patients, while others couldn't care less about their patients' ultimate well-being, with most falling somewhere in the middle. Likewise, those who are less-than-impressed by medical school are not guaranteed to be good with patient care - there are lots of reasons to dislike medical school and a desire for greater focus on patients is only one of them.
I will fully admit though that I get more than a little concerned about my ever-happy-with-medicine classmates, though I generally think they'll make good physicians, and the crux of that concern is that they're might not be seeing the faults or flaws in the current system. Calling medicine broken is a bit hyperbolic, but the further I get into it, the less hyperbole I see in that statement. There are some serious, deep issues in the medical professional that are going to take a long, concerted effort to change. I can't see those issues and not get upset that part of my training involves being forced to entrench those issues further, so to see people go through that process happily makes me worried that they'll be part of the next group of physicians fighting to keep the system broken...
If this whole post makes me sound like a pessimist, I want to stress that my frustration comes from a very deep-seated optimism. I dislike much of the current system of both medicine and medical education because it could be so much better and I believe we can make it better. I see so many colleagues with the intelligence and compassion to make productive changes; there's no shortage of ability. Yet, there may be a shortage of will. The more people with power who are happy with the status quo - and in medicine, people with power often means physicians - the more likely the status quo is going to stick around. In that sense, a few more dissatisfied medical students wouldn't be so bad...
Of course most people fall somewhere into the middle with a lean towards one side or the other, but I there are more than a few people decidedly on one end or the other.
I'm definitely in the latter category. Ok, I don't hate medical school, certainly not 100% of the time, but I'm frustrated with my experiences in medical school far more often than I've been happy or even satisfied with them. The second post linked almost perfectly explains why I feel this way: I got into medicine to connect with people in a meaningful way and, ideally, to have lasting, positive impact on their health and/or lives in general. Yet, medical school more often than not pushes me in the opposite direction.
Meaningful contact with other people - even simple human interaction like normal people do each and every day - is secondary and often discouraged. Much of the health care system, including a good portion under the control of physicians, does not seem designed to provide adequate care, let alone excellent care. As the lowest person on the totem pole, you have no choice but to go along with what I consider substandard or fractured care. I can hate it all I want, but not only do I have to put up with this system, I have to advance and at times defend that system.
Let me be clear - the care is substandard, but the medicine is usually (though not always) fine. And that gets to the heart of the divide in viewpoints on medical school. For me, medicine is the means to an end. I want to help people, but don't particularly care how as long as it's effective. Good medical care can have an incredibly beneficial effect on a person's life, but getting the medicine right is only the first step in getting good care. It's necessary, but not sufficient.
Yet for some physicians or physicians-to-be, the medicine isn't means to an end, it's an end itself. For those who love the medicine, I imagine medical school is great, it's very much focused on acquiring and refining medical knowledge. For those of us who are very much patient-focused, learning about the medicine at the expense of forgetting about the patients is not a worthwhile trade-off, even if it is (hopefully) a temporary one.
This is not to suggest that people who love medical school are not going to care about their patients. It's a spectrum - some people who love the medicine are keenly devoted to the well-being of their patients, while others couldn't care less about their patients' ultimate well-being, with most falling somewhere in the middle. Likewise, those who are less-than-impressed by medical school are not guaranteed to be good with patient care - there are lots of reasons to dislike medical school and a desire for greater focus on patients is only one of them.
I will fully admit though that I get more than a little concerned about my ever-happy-with-medicine classmates, though I generally think they'll make good physicians, and the crux of that concern is that they're might not be seeing the faults or flaws in the current system. Calling medicine broken is a bit hyperbolic, but the further I get into it, the less hyperbole I see in that statement. There are some serious, deep issues in the medical professional that are going to take a long, concerted effort to change. I can't see those issues and not get upset that part of my training involves being forced to entrench those issues further, so to see people go through that process happily makes me worried that they'll be part of the next group of physicians fighting to keep the system broken...
If this whole post makes me sound like a pessimist, I want to stress that my frustration comes from a very deep-seated optimism. I dislike much of the current system of both medicine and medical education because it could be so much better and I believe we can make it better. I see so many colleagues with the intelligence and compassion to make productive changes; there's no shortage of ability. Yet, there may be a shortage of will. The more people with power who are happy with the status quo - and in medicine, people with power often means physicians - the more likely the status quo is going to stick around. In that sense, a few more dissatisfied medical students wouldn't be so bad...
Thursday 10 December 2015
Predicting Specialty Competitiveness
I like to think I have a pretty good handle on specialty competitiveness. I spend way too much time pouring over CaRMS stats and have used them to calculate a few of my own numbers on competitiveness each year. (Disclaimer - my preferred metric, 1st iteration match rate by preferred specialty to that discipline, has been produced by the CFMS as part of their fantastic annual Matchbook each year, so I'm not coming up with much that's original).
Anyway, while historical match rates in each specialty are interesting, what everyone cares about is predicting future match rates! "Is X specialty more competitive this year than in the past?"
Well, I'm going to put my knowledge to the test. Based on last year's match rate, historical trends, current job market, changes in lifestyle/income, and random rumors I've heard, here are my predictions for the competitiveness of the larger CaRMS first-entry specialties:
Anesthesiology
2015 Match Rate: 71%
Mediocre (but not terrible) job market with a good lifestyle and good income. Has been trending towards being more competitive. Hearing this is a uniquely competitive year.
Predicted 2016 Match Rate: 67%
Dermatology
2015 Match Rate: 51%
Good job market, good pay, great lifestyle. Been quite competitive recently, but no reason to think that'll change. No rumors to report.
Predicted 2016 Match Rate: 53%
Diagnostic Radiology
2015 Match Rate: 74%
Mediocre job market, declining lifestyle, great income (but declining fast in Ontario). Historically competitive but much less so in the past few years. 2015 might have been close to where Rads was 10 years ago, but it's a divergence from the recent trend. A regression to its typical low-80's rate would be expected and word is applications are down this year.
Predicted 2016 Match Rate: 82%
Emergency Medicine
2015 Match Rate: 56%
Great job market, good pay, lifestyle either horrible or great depending on your feelings about shift work. EM became more competitive recently, but even then, last year saw a fair-sized drop in the match rate. A small regression wouldn't be surprising, but interest is still high and somehow the field lost two spots in this year's match (?!).
Predicted 2016 Match Rate: 56%
Family Medicine
2015 Match Rate: 96%
Great job market, low pay, moderate (but flexible) lifestyle. Interest in FM has been steadily growing and I hear this year is no exception, but it's also a widely-accepted back-up specialty, so more interest doesn't necessarily translate into a lower match rate. People backing up might just lose out. It's also a huge field, so the match rate can't drop by much without a massive swell of interest.
Predicted 2016 Match Rate: 95%
General Surgery
2015 Match Rate: 85%
Pretty poor job market, rough lifestyle, good pay. Interest in surgery overall is declining a bit. Haven't heard too much about this year's match.
Predicted 2016 Match Rate: 84%
Internal Medicine
2015 Match Rate: 95%
Variable lifestyle, income, and job market, depending on subspecialty. Seems to be losing interest from students, but it's still the second-largest specialty. Nothing in the rumor mill to report.
Predicted 2016 Match Rate: 95%
Neurology
2015 Match Rate: 79%
I probably know the least about Neuro's practice situation so take this one with a grain of salt. Widely variable match rate recently, but 2015 was oddly competitive. Expecting a regression.
Predicted 2016 Match Rate: 85%
Obstetrics & Gynecology
2015 Match Rate: 73%
Mediocre job market, reasonable pay, but rough lifestyle in many respects. Competitiveness has grown recently. Does the trend continue, plateau, or regress? Hard to say. My money's on plateau.
Predicted 2016 Match Rate: 75%
Ophthalmology
2015 Match Rate: 74%
Poor job market, but awesome lifestyle and incredibly high pay. Competitiveness jumps year-to-year, but the match rate is usually lower than 2015's 74%.
Predicted 2016 Match Rate: 68%
Orthopedic Surgery
2015 Match Rate: 90%
Terrible job market (in Canada at least), but plenty of demand for procedures. Pay's decent, lifestyle's typical for surgical specialties. It's declining in competitiveness for good reason, but surgical specialties still garner substantial interest.
Predicted 2016 Match Rate: 87%
Otolaryngology
2015 Match Rate: 62%
Bad job market, good pay, decent lifestyle for a surgical specialty. Bit of a uniquely competitive year in 2015, but I'm hearing that level of interest is holding up.
Predicted 2016 Match Rate: 63%
Pediatrics
2015 Match Rate: 80%
Alright job market, alright pay, alright hours. Really stable match rates, even for a large field. People either love it or hate it, so the interest stays pretty constant.
Predicted 2016 Match Rate: 79%
Physical Medicine & Rehabilitation
2015 Match Rate: 76%
Good job market, alright pay, good hours. Quickly becoming a recognized lifestyle specialty and not without cause. More interest in recent years has translated into a big jump in competitiveness of the specialty last year. No firm whispers to report, but it sounds like this is a sustainable change, rather than a blip.
Predicted 2016 Match Rate: 78%
Plastic Surgery
2015 Match Rate: 53%
Alright job market, for surgery at least (OR time still a bit of a problem). Decent lifestyle for a surgical specialty as well. Good pay. Has been consistently competitive, match rates <60% for the last 5 years. Don't expect that to change.
Predicted 2016 Match Rate: 55%
Psychiatry
2015 Match Rate: 88%
Great job market, good lifestyle, but low pay. Interest in the field has grown, but that growth has limits - many students rule out Psych early and definitively.
Predicted 2016 Match Rate: 88%
Urology
2015 Match Rate: 81%
Poor job market, but good pay, and on the better side of things lifestyle-wise for a surgical specialty. Was less competitive in 2015 than typical, expect slight regression.
Predicted 2016 Match Rate: 77%
I should probably define what I'll consider to be an accurate prediction. Since more competitive specialties also tend to be more variable, I'll count a "success" as being +/- 2% if my prediction is over 90%, +/- 3% if my prediction is between 75% and 90%, and +/- 4% if my prediction is below 75%. In any case, it's written down, we'll see how my predictions turn out!
Anyway, while historical match rates in each specialty are interesting, what everyone cares about is predicting future match rates! "Is X specialty more competitive this year than in the past?"
Well, I'm going to put my knowledge to the test. Based on last year's match rate, historical trends, current job market, changes in lifestyle/income, and random rumors I've heard, here are my predictions for the competitiveness of the larger CaRMS first-entry specialties:
Anesthesiology
2015 Match Rate: 71%
Mediocre (but not terrible) job market with a good lifestyle and good income. Has been trending towards being more competitive. Hearing this is a uniquely competitive year.
Predicted 2016 Match Rate: 67%
Dermatology
2015 Match Rate: 51%
Good job market, good pay, great lifestyle. Been quite competitive recently, but no reason to think that'll change. No rumors to report.
Predicted 2016 Match Rate: 53%
Diagnostic Radiology
2015 Match Rate: 74%
Mediocre job market, declining lifestyle, great income (but declining fast in Ontario). Historically competitive but much less so in the past few years. 2015 might have been close to where Rads was 10 years ago, but it's a divergence from the recent trend. A regression to its typical low-80's rate would be expected and word is applications are down this year.
Predicted 2016 Match Rate: 82%
Emergency Medicine
2015 Match Rate: 56%
Great job market, good pay, lifestyle either horrible or great depending on your feelings about shift work. EM became more competitive recently, but even then, last year saw a fair-sized drop in the match rate. A small regression wouldn't be surprising, but interest is still high and somehow the field lost two spots in this year's match (?!).
Predicted 2016 Match Rate: 56%
Family Medicine
2015 Match Rate: 96%
Great job market, low pay, moderate (but flexible) lifestyle. Interest in FM has been steadily growing and I hear this year is no exception, but it's also a widely-accepted back-up specialty, so more interest doesn't necessarily translate into a lower match rate. People backing up might just lose out. It's also a huge field, so the match rate can't drop by much without a massive swell of interest.
Predicted 2016 Match Rate: 95%
General Surgery
2015 Match Rate: 85%
Pretty poor job market, rough lifestyle, good pay. Interest in surgery overall is declining a bit. Haven't heard too much about this year's match.
Predicted 2016 Match Rate: 84%
Internal Medicine
2015 Match Rate: 95%
Variable lifestyle, income, and job market, depending on subspecialty. Seems to be losing interest from students, but it's still the second-largest specialty. Nothing in the rumor mill to report.
Predicted 2016 Match Rate: 95%
Neurology
2015 Match Rate: 79%
I probably know the least about Neuro's practice situation so take this one with a grain of salt. Widely variable match rate recently, but 2015 was oddly competitive. Expecting a regression.
Predicted 2016 Match Rate: 85%
Obstetrics & Gynecology
2015 Match Rate: 73%
Mediocre job market, reasonable pay, but rough lifestyle in many respects. Competitiveness has grown recently. Does the trend continue, plateau, or regress? Hard to say. My money's on plateau.
Predicted 2016 Match Rate: 75%
Ophthalmology
2015 Match Rate: 74%
Poor job market, but awesome lifestyle and incredibly high pay. Competitiveness jumps year-to-year, but the match rate is usually lower than 2015's 74%.
Predicted 2016 Match Rate: 68%
Orthopedic Surgery
2015 Match Rate: 90%
Terrible job market (in Canada at least), but plenty of demand for procedures. Pay's decent, lifestyle's typical for surgical specialties. It's declining in competitiveness for good reason, but surgical specialties still garner substantial interest.
Predicted 2016 Match Rate: 87%
Otolaryngology
2015 Match Rate: 62%
Bad job market, good pay, decent lifestyle for a surgical specialty. Bit of a uniquely competitive year in 2015, but I'm hearing that level of interest is holding up.
Predicted 2016 Match Rate: 63%
Pediatrics
2015 Match Rate: 80%
Alright job market, alright pay, alright hours. Really stable match rates, even for a large field. People either love it or hate it, so the interest stays pretty constant.
Predicted 2016 Match Rate: 79%
Physical Medicine & Rehabilitation
2015 Match Rate: 76%
Good job market, alright pay, good hours. Quickly becoming a recognized lifestyle specialty and not without cause. More interest in recent years has translated into a big jump in competitiveness of the specialty last year. No firm whispers to report, but it sounds like this is a sustainable change, rather than a blip.
Predicted 2016 Match Rate: 78%
Plastic Surgery
2015 Match Rate: 53%
Alright job market, for surgery at least (OR time still a bit of a problem). Decent lifestyle for a surgical specialty as well. Good pay. Has been consistently competitive, match rates <60% for the last 5 years. Don't expect that to change.
Predicted 2016 Match Rate: 55%
Psychiatry
2015 Match Rate: 88%
Great job market, good lifestyle, but low pay. Interest in the field has grown, but that growth has limits - many students rule out Psych early and definitively.
Predicted 2016 Match Rate: 88%
Urology
2015 Match Rate: 81%
Poor job market, but good pay, and on the better side of things lifestyle-wise for a surgical specialty. Was less competitive in 2015 than typical, expect slight regression.
Predicted 2016 Match Rate: 77%
I should probably define what I'll consider to be an accurate prediction. Since more competitive specialties also tend to be more variable, I'll count a "success" as being +/- 2% if my prediction is over 90%, +/- 3% if my prediction is between 75% and 90%, and +/- 4% if my prediction is below 75%. In any case, it's written down, we'll see how my predictions turn out!
Wednesday 9 December 2015
Likes and Dislikes in Emergency Medicine
My school gives us a very quick rotation through our hospitals' Emergency Departments. It's been pretty fun! Here's what I've taken away from my brief time in the rotation:
1) Scope of practice: everything
Everything comes through the ED. Every body system, every age, every stage of life. Sure, there's the bread-and-butter conditions (I've seen a lot of chest pain this week), but the variety is really unique compared to other specialties. I've had more "firsts" in my medical training this past week alone than in the previous 3 months of clerkship and 2 years of pre-clerkship. I'd say this is the first rotation where I've come home excited on a regular basis and it's because I've gotten to do something different every day. I'm really enjoying the diversity of conditions in the ED.
2) Oh, shift work...
The best and the worst part of EM is the same - you're working shift work at all times of the day. It's a bit disorienting. This week I got off a shift at 11 pm, then started my next one at 9 am the following day. I've got a shift that ends at 4 am in a few days. That throws off your internal clock a bit...
On the plus side, shift work is limited to, well, shifts. If you're scheduled for 8 hours, you get off after about 8 hours, with maybe half an hour or so to wrap up patients. You get days off, even during the week, to do things that normal people do like run errands, get exercise, and watch copious amounts of TV. For attending, shift work also means things like taking vacation are fairly easy to do. EM docs don't have their own patients, so any shift can be covered by any qualified EM physician. That makes taking some time off easy, you just ask to not have any shifts during a given period of time!
3) Process Improvement
I've been very frustrated with how the medical system (and the medical education system) is organized, especially within individual departments. The processes in place don't seem set up to optimize outcomes for patients, providers, or students. Worse, efforts to improve these systems are non-existent or face substantial resistance from those in positions of power (often physicians).
In that respect, the ED has been a breath of fresh air, at least at my institution. The system isn't perfect, but it's clear efforts have been made to improve experiences for patients and physicians alike. More importantly, there seems to be a lot of energy being devoted to making the system better. Emergency departments have, rightfully, been the focus of a fair bit of criticism in the past, so maybe this is just a natural outflow of the field's past weaknesses, but I can't say how happy I am to see the status quo in medicine under scrutiny.
4) Rush, rush, rush
Everything moves pretty quickly in the ED. As a student, I'm usually at least partially shielded from the true craziness, but students aren't fully immune to the department's brisk pace. Most times I've been on so far, it'd been me working with a staff physician and a resident. Today, the resident called in sick and I was running off my feet trying to get patients moved through (or at least not slow down those who were actually moving patients through). It was both exhilarating and exhausting.
5) Not my job
If there's one thing I really didn't like about being in the ED, it's that they have a very specific role in health care. Once a patient is stable and there are no acute interventions to do for whatever brought them in, that's it, they're either going to be admitted or sent home. In most cases, this works just fine. In a select few, however, I found it a bit frustrating to go through a whole work-up that basically gave us the diagnosis, which has an obvious longer-term treatment that's easy enough for us to start in the ED, but we held off in favour of having them follow-up with a clinic or their Family Physician. I get it, long-term stuff should be covered by a physician following them long-term, but it sucks to get 90% of the way to solving the patient's problem and stop short of finishing the job.
6) The Happiness Test
The ED is a high-stress environment, where in any given shift, several of your patients could be at risk of death if not managed properly. When we're on the job and running around, I've certainly seen the serious, no-nonsense side of Emerg physicians come out. Yet, the second we have a chance to sit down, the seriousness disappears instantly and the smiles come out. Every physician I've worked with so far seems pretty happy, usually joking around between reviewing patients. They've all been incredibly nice to me so far. Maybe it's just my institution, maybe the only people drawn to the field are those who can handle stress with a smile, but I have to consider EM docs positive on the Happiness Test.
1) Scope of practice: everything
Everything comes through the ED. Every body system, every age, every stage of life. Sure, there's the bread-and-butter conditions (I've seen a lot of chest pain this week), but the variety is really unique compared to other specialties. I've had more "firsts" in my medical training this past week alone than in the previous 3 months of clerkship and 2 years of pre-clerkship. I'd say this is the first rotation where I've come home excited on a regular basis and it's because I've gotten to do something different every day. I'm really enjoying the diversity of conditions in the ED.
2) Oh, shift work...
The best and the worst part of EM is the same - you're working shift work at all times of the day. It's a bit disorienting. This week I got off a shift at 11 pm, then started my next one at 9 am the following day. I've got a shift that ends at 4 am in a few days. That throws off your internal clock a bit...
On the plus side, shift work is limited to, well, shifts. If you're scheduled for 8 hours, you get off after about 8 hours, with maybe half an hour or so to wrap up patients. You get days off, even during the week, to do things that normal people do like run errands, get exercise, and watch copious amounts of TV. For attending, shift work also means things like taking vacation are fairly easy to do. EM docs don't have their own patients, so any shift can be covered by any qualified EM physician. That makes taking some time off easy, you just ask to not have any shifts during a given period of time!
3) Process Improvement
I've been very frustrated with how the medical system (and the medical education system) is organized, especially within individual departments. The processes in place don't seem set up to optimize outcomes for patients, providers, or students. Worse, efforts to improve these systems are non-existent or face substantial resistance from those in positions of power (often physicians).
In that respect, the ED has been a breath of fresh air, at least at my institution. The system isn't perfect, but it's clear efforts have been made to improve experiences for patients and physicians alike. More importantly, there seems to be a lot of energy being devoted to making the system better. Emergency departments have, rightfully, been the focus of a fair bit of criticism in the past, so maybe this is just a natural outflow of the field's past weaknesses, but I can't say how happy I am to see the status quo in medicine under scrutiny.
4) Rush, rush, rush
Everything moves pretty quickly in the ED. As a student, I'm usually at least partially shielded from the true craziness, but students aren't fully immune to the department's brisk pace. Most times I've been on so far, it'd been me working with a staff physician and a resident. Today, the resident called in sick and I was running off my feet trying to get patients moved through (or at least not slow down those who were actually moving patients through). It was both exhilarating and exhausting.
5) Not my job
If there's one thing I really didn't like about being in the ED, it's that they have a very specific role in health care. Once a patient is stable and there are no acute interventions to do for whatever brought them in, that's it, they're either going to be admitted or sent home. In most cases, this works just fine. In a select few, however, I found it a bit frustrating to go through a whole work-up that basically gave us the diagnosis, which has an obvious longer-term treatment that's easy enough for us to start in the ED, but we held off in favour of having them follow-up with a clinic or their Family Physician. I get it, long-term stuff should be covered by a physician following them long-term, but it sucks to get 90% of the way to solving the patient's problem and stop short of finishing the job.
6) The Happiness Test
The ED is a high-stress environment, where in any given shift, several of your patients could be at risk of death if not managed properly. When we're on the job and running around, I've certainly seen the serious, no-nonsense side of Emerg physicians come out. Yet, the second we have a chance to sit down, the seriousness disappears instantly and the smiles come out. Every physician I've worked with so far seems pretty happy, usually joking around between reviewing patients. They've all been incredibly nice to me so far. Maybe it's just my institution, maybe the only people drawn to the field are those who can handle stress with a smile, but I have to consider EM docs positive on the Happiness Test.
Monday 7 December 2015
Roles of a Physician
One common story about the horrors of being a Clerk is the need to do what's called "scutwork", which is basically doing annoying tasks that anyone can do but which no one wants to do. Clerks get to do these tasks because they're at the bottom of the totem pole in medicine and they can't say "no".
So far though, I haven't had any real scutwork to do. My previous work in healthcare definitely involved some of this, both as a student and as a practitioner. I collected garbage, changed linens, transported patients, ran blood samples to the lab... whatever needed to be done. Not the most fun work, but it served a useful purpose and was clearly part of my job. Physicians largely don't have these kinds of responsibilities - there are ancillary staff who take on these tasks - and so Clerks don't have to do it either. There's been very minimal menial labour so far (unless you count writing notes which, while monotonous at times, is usually very necessary patient care).
In some ways though, I wish there was some scutwork. Changing linens was annoying at times, but it was easy and a very tangible way to contribute. For Clerks, who really aren't good for much productive on the medical side of things yet, there are worse things than having an easy, useful task to complete that others would rather not do.
More importantly, I think it's worth remembering that an MD says what we can do, not what we can't. Physicians are very privileged to be able to do almost any task in healthcare, including some very cool, very useful activities that most other people are legally not allowed to perform. But just because there are virtually no tasks above the scope of practice for a physician, that doesn't mean there are skills below the scope of practice for a physician. I can still bring a patient their meal. I can still bring them a blanket. I can still change the linen basket in their room.
I won't do these activities on a regular basis - there are people paid specifically to do these tasks and they know how to do them more efficiently than I do - but like most people, I got into medicine to help people. If that means performing a careful examination, doing appropriate tests, formulating an accurate diagnosis and determining appropriate treatment, great. If that means grabbing a warm blanket from the warming cabinet, also great. In all honesty, sometimes I wish I got to grab more blankets for patients - it really can go a long way to make them feel better when they otherwise might not feel all that great.
Wednesday 2 December 2015
Do a Full History and Physical
Here's a tip to current instructors of medical students, as well as to hopefully myself in the future: never tell a student to do a "full history and physical" without defining exactly what that means in the given context. I've gotten that piece of advice from a huge number of instructors and residents, some of them otherwise very good instructors.
The idea, presumably, is that I should be thorough at my stage in training. Lacking enough experience to know exactly what the right questions are, it's better to ask too many questions and have some be meaningless than to ask too few and miss important details. Same goes for physical exam - too much is preferable to too little. That I get.
But a true "full history" would be a waste of time for everyone involved, not least for the patient. I can ask every question I can think of, even if it's unlikely to have any relevance. I can do every physical exam test I know of, but most would be useless if not nonsensical. What most people mean when they say "do a full history and physical" is "cover the standard questions and examinations for this specialty". Yet, what the standard is changes from specialty to specialty, sometimes dramatically. In kids I learned that I should pretty much always look in their ears. In adults? Not so much. The only way to know that for an otherwise naive student is to be told.
That's where "do a full history and physical" really fails - it's specific to the speaker, who lives wholly within the context of one specialty, but is vague to the listener, who jumps between specialties with regularity.
So in the future, when talking to an undifferentiated learner in medicine, please, just say "always ask this, this and this, then do this, this and this on exam". It'll be far more helpful than to say "do a full history and physical".
The idea, presumably, is that I should be thorough at my stage in training. Lacking enough experience to know exactly what the right questions are, it's better to ask too many questions and have some be meaningless than to ask too few and miss important details. Same goes for physical exam - too much is preferable to too little. That I get.
But a true "full history" would be a waste of time for everyone involved, not least for the patient. I can ask every question I can think of, even if it's unlikely to have any relevance. I can do every physical exam test I know of, but most would be useless if not nonsensical. What most people mean when they say "do a full history and physical" is "cover the standard questions and examinations for this specialty". Yet, what the standard is changes from specialty to specialty, sometimes dramatically. In kids I learned that I should pretty much always look in their ears. In adults? Not so much. The only way to know that for an otherwise naive student is to be told.
That's where "do a full history and physical" really fails - it's specific to the speaker, who lives wholly within the context of one specialty, but is vague to the listener, who jumps between specialties with regularity.
So in the future, when talking to an undifferentiated learner in medicine, please, just say "always ask this, this and this, then do this, this and this on exam". It'll be far more helpful than to say "do a full history and physical".
Tuesday 1 December 2015
Med School Curriculums Across Ontario
One interesting aspect of clerkship is you get a lot more exposure to students who are going or went to different medical schools across the country. We have elective students rotating through working with us, and many of our residents trained at other schools originally. I go to an Ontario school, so most people I encounter are from Ontario schools as well, but there's still a fair bit of variety. One topic that's come up a lot in conversation - and I swear I'm not initiating these because I'm a medical education geek - is how our schedules in clerkship and medical school in general differ. It's interesting to see what each school considers important enough to specifically highlight in clerkship, or what parts of school come where during the 3 or 4 years. Talking with the McMaster students has been the most interesting, because they have a 3 year program that's all over the place.
In broad strokes, most schools still do the traditional North American model for medical school:
Years 1 & 2: Pre-clerkship, consisting of lectures, small groups, plus some training taking a basic history and physical.
Year 3: Core clerkship, consisting of a standard set of rotations (IM/Gen Surg/FM/Psych/Peds/OBGYN with ER and/or Anesth often thrown in there somewhere)
Year 4: Electives, where you do whatever you want wherever you want to tailor your education (but mostly to impress whoever you want to impress for CaRMS).
Pre-clerkship years typically come with a few months of summer while Year 4 ends early to allow time off before residencies which start in July.
Talking to current or former students from other schools, I've gleaned a few take-aways on how medical school could or should be set up:
1) Rotation length isn't that important in clerkship. My school does 6 week blocks for its core rotations, often broken down into sub-rotations of 2 weeks each. IM and Surgery are combined into 12 week blocks, but get some more selective time. Other schools seem to do 4 week blocks and include selective-only blocks. Doesn't seem to make much difference. I generally like the way my school has broadly organized its clerkship, but see nothing wrong with the other systems.
2) Core rotations should come before electives. McMaster doesn't just do a 3 year program, it does a very jumbled 3-year program. Electives come before core rotations in a lot of cases and students don't seem to like that at all.
3) Electives are for CaRMS - and the more pre-CaRMS electives the better. Regardless of what schools or programs think electives are for, students are very clear: they're for finding out what the right residency is and matching to it.
4) 3-year programs are completely viable. McMaster unfortunately has a reputation that its clerks are less knowledgeable than clerks from 4-year schools. I've seen signs of this, but nothing consistent or egregious. More importantly, the school's match rate is good, former Mac students do fine as R1s and also do fine once they get out into practice. Maybe there's a small deficit in medical school, but who cares? School's meant to be a learning experience and the end-outcomes are fine.
With these in mind, I'd like to propose the following broad curriculum schedule for medical schools:
Year 1 (Sept-May): Preclerkship, consisting of lectures & small groups, with a heavy emphasis on practical skills like taking a basic history and physical. One month of summer in June for travel and stuff.
Year 2 (July-June): Clerkship, consisting of the standard set of core rotations. Some weeks of didactic training would be interspersed to make up for a shortened pre-clerkship.
Year 3 (July- May): Electives, consisting of in-hospital electives until end of Dec with in-class/simulation electives and consolidation from Jan-May.
The idea here is to sacrifice a good chunk of pre-clerkship and some in-hospital training during clerkship itself in favour of increased elective time (particularly pre-CaRMS elective time) and one less year of training. First year would be an utter crash course in medicine, focusing on the sheer basics. Some things undoubtedly get lost by cutting out what amounts to about 9 months of in-class instruction, but short training times also force some efficiency on curriculum designers and mean there's not much time for knowledge to be lost before clerkship. Pre-clerkship is pretty inefficient, with plenty of low-yield content and poor approaches to long-term learning. Off the top of my head I can think of several months worth of material that could be tossed from my school's pre-clerkship curriculum without much consequence - there's plenty of fat to cut before getting to the meat of pre-clerkship.
The chance to make up that depth comes in increased clerkship classroom-based instruction. I'm pretty outspoken about how lectures are rather useless, but there is a role for hands-off learning in applied fields like medicine. By linking teaching more closely with clinical experiences, the chances of long-term retention are much higher.
The increased elective time is pretty self-explanatory and mostly just represents a re-scheduling. At my school, we get quite a few selectives through our third year, which are often quite enjoyable rotations, but are hardly necessary. By switching these out for true electives students can get a bit more control over their future and have more time to feel out their career goals, especially before having to apply for residencies.
This system would not be without its own downsides, but I think on the balance far more is gained than lost. As always, I'd love to hear opinions on such a system, positive or negative - it's something that's been rattling around in my head for a while, and it's been good to type it out!
In broad strokes, most schools still do the traditional North American model for medical school:
Years 1 & 2: Pre-clerkship, consisting of lectures, small groups, plus some training taking a basic history and physical.
Year 3: Core clerkship, consisting of a standard set of rotations (IM/Gen Surg/FM/Psych/Peds/OBGYN with ER and/or Anesth often thrown in there somewhere)
Year 4: Electives, where you do whatever you want wherever you want to tailor your education (but mostly to impress whoever you want to impress for CaRMS).
Pre-clerkship years typically come with a few months of summer while Year 4 ends early to allow time off before residencies which start in July.
Talking to current or former students from other schools, I've gleaned a few take-aways on how medical school could or should be set up:
1) Rotation length isn't that important in clerkship. My school does 6 week blocks for its core rotations, often broken down into sub-rotations of 2 weeks each. IM and Surgery are combined into 12 week blocks, but get some more selective time. Other schools seem to do 4 week blocks and include selective-only blocks. Doesn't seem to make much difference. I generally like the way my school has broadly organized its clerkship, but see nothing wrong with the other systems.
2) Core rotations should come before electives. McMaster doesn't just do a 3 year program, it does a very jumbled 3-year program. Electives come before core rotations in a lot of cases and students don't seem to like that at all.
3) Electives are for CaRMS - and the more pre-CaRMS electives the better. Regardless of what schools or programs think electives are for, students are very clear: they're for finding out what the right residency is and matching to it.
4) 3-year programs are completely viable. McMaster unfortunately has a reputation that its clerks are less knowledgeable than clerks from 4-year schools. I've seen signs of this, but nothing consistent or egregious. More importantly, the school's match rate is good, former Mac students do fine as R1s and also do fine once they get out into practice. Maybe there's a small deficit in medical school, but who cares? School's meant to be a learning experience and the end-outcomes are fine.
With these in mind, I'd like to propose the following broad curriculum schedule for medical schools:
Year 1 (Sept-May): Preclerkship, consisting of lectures & small groups, with a heavy emphasis on practical skills like taking a basic history and physical. One month of summer in June for travel and stuff.
Year 2 (July-June): Clerkship, consisting of the standard set of core rotations. Some weeks of didactic training would be interspersed to make up for a shortened pre-clerkship.
Year 3 (July- May): Electives, consisting of in-hospital electives until end of Dec with in-class/simulation electives and consolidation from Jan-May.
The idea here is to sacrifice a good chunk of pre-clerkship and some in-hospital training during clerkship itself in favour of increased elective time (particularly pre-CaRMS elective time) and one less year of training. First year would be an utter crash course in medicine, focusing on the sheer basics. Some things undoubtedly get lost by cutting out what amounts to about 9 months of in-class instruction, but short training times also force some efficiency on curriculum designers and mean there's not much time for knowledge to be lost before clerkship. Pre-clerkship is pretty inefficient, with plenty of low-yield content and poor approaches to long-term learning. Off the top of my head I can think of several months worth of material that could be tossed from my school's pre-clerkship curriculum without much consequence - there's plenty of fat to cut before getting to the meat of pre-clerkship.
The chance to make up that depth comes in increased clerkship classroom-based instruction. I'm pretty outspoken about how lectures are rather useless, but there is a role for hands-off learning in applied fields like medicine. By linking teaching more closely with clinical experiences, the chances of long-term retention are much higher.
The increased elective time is pretty self-explanatory and mostly just represents a re-scheduling. At my school, we get quite a few selectives through our third year, which are often quite enjoyable rotations, but are hardly necessary. By switching these out for true electives students can get a bit more control over their future and have more time to feel out their career goals, especially before having to apply for residencies.
This system would not be without its own downsides, but I think on the balance far more is gained than lost. As always, I'd love to hear opinions on such a system, positive or negative - it's something that's been rattling around in my head for a while, and it's been good to type it out!
Subscribe to:
Posts (Atom)