Syrian Refugees

As the situation unfolds and worsens in Syria, I'm reminded of the interactions I've had with recently-arrived refugees from Syria to Canada. As healthcare was not always present in great quality in Syria or the refugee camps that most of these arrivals to Canada spent the last 5+ years, many ended up arriving with neglected medical conditions. Some of these have been quite dramatic - without providing details, some of these refugees realistically would have died years ago but through some combination of willpower or sheer luck managed to survive to this point. Some very unique cases have made their way to the hospitals in Canada, and are fortunately receiving care.

Canada has had the enormous luxury of choosing exactly which Syrian families get to arrive. We've clearly been discerning in our selection process, with families with children being the main cohort. We have more opportunity to vet potential refugees than most other countries. Canada has had a large number of people, community groups, and national organizations provide voluntary support to these new arrivals.

Immigration is an area of significant contention around the world and Canada is no exception. I personally find many flaws in our current immigration system, as well as in proposed changes to that system from pretty much all political parties. Movement of people around the globe and how we respond to a desire of people to move from country to country is a complex problem, which often gets discussed in overly simplistic terms. As a relatively desirable destination with a long history of significant immigration, but one which is remote and small (population-wise), Canada faces some unique challenges here. I'm far from being convinced we should be increasing opportunities for immigration to Canada.

Still, I won't go into my full views on immigration here, in no small part because I haven't had as much opportunity to read about the topic and think through the issues. However, when it comes to refugees, particularly those from Syria, I can't help but think we made a good move to accept those we have, as small a number as that is. The people I've met where under significant threat of harm or death, via war or neglect. Even the best-off saw standards of living well below what I'd consider acceptable, in ways that would prevent them from being able to work towards the improvement of the situation around them. They needed somewhere to go from where they were. We can't accept everyone - and clearly we didn't - but we have the room for these people and the resources to get them started on a decent, productive life in Canada. I enjoyed being very small part of that process.

Vacation Sick, Once Again

My school has us finishing up our clinical electives in December, which leaves us a full 2 weeks off during the holiday season, a nice break after having had only 3 weeks off total in the last 16 months. It's a nice opportunity to de-stress before CaRMS interviews and the last set of coursework over the winter.

So, of course, it's time for me to get sick again. It's just a cold this time, thankfully, so it's not too bad, but once again, any off time has to come with some sort of illness. I'm not even upset anymore, more wondering how/why this keeps happening. My guess is either that I'm carrying around an infection pretty much constantly, but that my immune system is constantly suppressed by stress and fatigue while on clinical placements, or my immune system is just terrible all the time and I lose my protective layer of alcohol-based hand wash when out of a hospital setting.

The next break I get will come during the CaRMS interview tour in just a few weeks, as my relatively small number of interviews gets contrasted with my school's very generous amount of time off for these interviews. For a variety or reasons, I'm hoping my sick-during-vacation streak gets broken this time around...

Combating Depression in Medical Trainees

Following-up quickly on the previous post, because identifying a problem is fairly meaningless if you can't do anything about it. I said in that post that there are no simple answers and that's definitely true. Equally important to note is that whatever responses to this problem I present (or that anyone else presents) will likely not have much of an evidence base behind them, as there isn't much good research on this problem in particular. Reasonable theories is about all we have at this stage. In any case, if I had some all-powerful influence over medical education policies, here's what I'd try.

1) Reduce Hours

Physicians work a lot. Residents work a lot more. Medical students work less, but still quite a bit. All work more than a standard 40-hour week. Heck, a 40-hour week ever is practically luxurious. A fair bit of unofficial work is also effectively required, whether that's administrative work, reading, teaching, or research. At the extreme ends, typically residents in high-intensity fields, 100+ hours per week is commonplace (out of a total of 168 hours in a week).

While many people avoid depression despite these long hours, it's hard to see how the rate of depression and depressive symptoms goes down without some relaxation in work hours. There are many ways to treat or prevent depression, but many of them take time, time which is not available when working 100+ hours per week. Basic self-care suffers under such schedules, let alone the extra care needed to maintain or improve mental health. The correlation between resident work hours and sleep is pretty clear, for example - more hours at the hospital means less sleep overall.

Simple work hour limits have been put in place in the US to some effect, but with significant limitations. Part of the problem with straight work hour limits is that programs still need the same amount of work done by the same number of people, just with fewer hours. So, residency programs find inventive ways to get the same work done by the same number of people through creative (often undesirable) scheduling, increasing workloads during worked hours, or straight-up lying about hours worked (particularly common in surgical specialties in the US).

Another concern with reduced working hours is that it may require extension in the number of years of residency in order to maintain the number of total hours worked and allow residents to gain the necessary experience to become competent. A certain amount of exposure to a given pathology or procedure is necessary to be able to work independently, of course. The argument here is that if residency is going to be terrible, it might as well be as compact as possible to allow physicians to move onto independent practice.

All things considered, I don't believe reducing work hours alone will be particularly effective in reducing depression among residents, but I do believe it is a necessary component to any solution. I believe it needs to come in conjunction with efforts to make residency training more effective in terms of educational outcomes, and more efficient in terms of workload completion. I see substantial room for improvement on both these fronts.

2) Orientation and Role Definition

One thing that's always struck me about medicine is how little orientation people get to their surroundings. Physicians-in-training are thrown into situations without any idea as to what their responsibilities are or how to carry out those responsibilities. I had a better orientation when I worked at McDonald's in high school than I have at any point during my medical training.

The disjointed nature of medical training does not help this process. During my clerkship, I had one rotation that lasted 6 weeks, one rotation that lasted 4 weeks, and one rotation that lasted 3 weeks. Everything else lasted for 2 weeks or less. By the end of a 2 week rotation, I would usually have a decent idea as to what I was supposed to be doing and how to start doing it somewhat effectively, but by that point, it was onto the next rotation and the whole process started over again.

Having a clear role, and having that role understood by those around you (especially superiors) is an important factor in overall job satisfaction. I see little reason to think this doesn't apply equally to physicians-in-training.

Ideally this would be accomplished with dedicated time for orientation combined with a degree of standardization of roles for learners between all rotations, but that may be overly ambitious. An easier change to implement could be simply having instructions for trainees put down in writing and communicated to both learners and instructors. This would not take much effort to accomplish, yet I found this simple document was not present for most of my rotations.

3) Allow Greater Flexibility in Education

Working hard, long hours sucks. Working hard, long hours you have some say over sucks a whole lot less. People who have control over their schedules tend to have much higher satisfaction with their work and their lives.

Realistically, students and residents are never going to have complete autonomy over their schedules. Yet, they could have a lot more control than they currently have. When talking about long hours, while many would prefer intensive, shorter residencies, some may want longer residencies with more favourable hours - yet this is an option only at a small handful of residency programs (usually Family Medicine programs).

Likewise, there are a lot of aspects to medical training which are mandatory across-the-board without having across-the-board value. My school has 12 weeks of required surgical training, yet the majority of students will never step foot in an OR after finishing residency. Likewise, of those who are going to be in the OR, do they need the full 6 weeks of training in both Family Medicine and another 6 weeks in Psychiatry? Would half the training in each make that much of a difference in overall competence once training is completed? Could that time be better spent if freed up for more electives or selectives? Some training in surgery, psychiatry, and family medicine seems necessary for all physicians, but additional exposure comes with diminishing returns.

Similarly, having some control over productivity within the day-to-day schedule may be beneficial. Pretty much every residency program has academic half-days and function well enough with residents missing for a period of time to attend mandatory lectures. Would it be possible to give residents a half-day to set their own schedules, whether that's working on research, attending specific clinics, or gaining more experience with useful procedures.

4) Just Treat Each Other Better!

Physicians aren't terribly nice to each other. I believe we're largely past the times where physicians used to be outright cruel to each other, but kindness is still often lacking. Encouraging words come far less frequently than they could or should. Gratitude between physicians is less frequent and less genuine than it could be ("Thank you for sending us this consult" isn't really a statement of appreciation as much as a nicety). When someone is sick, or needs to go pick up their kid from daycare, or just struggling to keep up, would it be that terrible to send them home when there's enough people around to do the work at hand - even if it means a little extra effort on the part of those left? All my other jobs managed these situations well enough, including those in health care.

5) Wellness Programs

In general, I'm not a fan of wellness programs currently being rolled out at many medical education institutions. They feel like trying to put a small bandage on a wound after waving around a knife that inflicted the wound in the first place. It's better than nothing, but not nearly adequate and doesn't address why a bandage was necessary in the first place. I find them to be inconvenient for most people and maintains the onus on trainees to help themselves. They often provide resources that are already available in the community in one form or another. As a result, they are often most utilized by those already motivated to improve their situations and willing to make sacrifices to do so - individuals who might have been able to pull themselves up even without a dedicated wellness program.

Still, some of the typical elements of wellness programs have some good evidence behind them. Meditation, yoga, and tai chi do have some benefits to mental health - as does exercise and mindfulness in general. Opportunities to talk through problems, or to reflect on them individually, can both be beneficial. Being able to reframe problems as opportunities, to develop a problem-solving attitude, can be quite useful in forming resilience to challenges. While I dislike the emphasis on wellness programs, they can be part of the solution for a subset of trainees.

To wrap things up, we're never going to eliminate depression or other forms of mental health problems from medicine. There will always be some medical students, residents, and staff struggling with low mood. However, it's clear that the rates of depression are higher than baseline, well higher than they could be given the resources the profession has at its disposal, and certainly higher than is ideal for high-quality patient care. There's a lot we could be doing to minimize this problem.

CaRMS Update - Interviews

My CaRMS cycle is in full swing, so I thought I'd post a quick update. After significant waffling, I applied to Family Medicine and only Family Medicine.

I was considering applying to Pediatrics as well, and set up a number of electives in the field to keep that option open. I enjoyed them thoroughly and was encouraged to consider applying by my preceptors, but ultimately decided against it. I love working with kids and the people in pediatrics I found to be particularly caring and compassionate, but the extra years of training, the high focus on inpatient care, and the comparatively worse job market (it's not bad in pediatrics, but not nearly as favourable as Family Medicine) was enough to dissuade me. I spent weeks going back and forth on whether I would apply, and if I did, how highly I would rank Pediatrics programs - this was not an easy decision.

I had a somewhat smaller conundrum after a Psychiatry elective which was similarly enjoyable and also resulted in a preceptor encouraging me to apply to the specialty. I wasn't really set up to do that - not enough elective experience, no real opportunities to get enough good LORs in the field, a CV that wasn't particularly well-tailored to Psychiatry. Still, similar to Pediatrics, I could envision a happy career in Psychiatry. It's hard not to wonder what opportunities would have been in store if I followed these preceptors' advice to enter a field beside Family Medicine.

Still, I'm quite happy with my decision. Family Medicine offers a rather quick path to a good job, with flexibility in opportunities, and a wide variety of patients to take care of. Having a relatively stress-free CaRMS application cycle doesn't hurt either. The match rate to Family Medicine is over 95% and I'm not banking on overly competitive locations. I don't feel nearly the same pressure a lot of my classmates are feeling.

Nevertheless, I'm not taking anything for granted. Family Medicine is what I want to match to and I'm not taking it anymore lightly than those in my class going for super-competitive specialties like Dermatology, Plastics, or Emergency Medicine. It's been reassuring to start getting interviews. I only applied to 5 schools, though there are 14 programs on my list between those 5 schools. I've been lucky enough to receive invites for interviews at 4 of these schools so far and am waiting to hear back from the fifth school. I'm fairly confident in my interviewing abilities, but have still been casually going over some questions and have set up some interview prep sessions offered by my school as well as the CMA. I didn't apply all that broadly, so I need to make each application and each interview count.

On the plus side, my smaller number of interviews means I'm going to have a lot of time off during the CaRMS interview period. My school gives those three weeks entirely off - an amazing and welcome decision on their part - and I'll likely only need a week or so of that time. Gives me both plenty of time to do some last-minute preparation, as well as time to recover afterwards!

Depression in Medicine

JAMA recently published a meta-analysis of studies on depression in resident physicians, and it's understandably getting a fair bit of attention. The headlining number approximately 28.8% of residents report depression or depressive symptoms. This is almost certainly a bit of an over-estimate as depressive symptoms aren't necessarily equal to depression itself - particularly when it comes to the somatic symptoms of depression (fatigue, poor sleep, appetite changes), there can be multiple explanations aside from depression.

Still, it's likely not a gross over-estimation. A rate around 20% or so, with approximately half of that being only moderate depression, fits with what the more granular data in the study suggests as well as with my own personal experience. The challenge with depression in medical school is that there is a strong incentive not to let on that you're going through it. The stigma against physicians with mental health problems is lessening, but there are still risks to opening up about it, especially as so much in medical training is subjective. Admitting to dealing with depression wouldn't be met with scorn, but might lose a student or resident the benefit of the doubt when mistakes or misses happen - which they inevitably do for all learners. Showing outward signs of depression can be equally harmful to a trainee's prospects - fatigue, irritability, and disinterest are all significantly frowned upon, even in situations where it might be completely reasonable to feel all three. The outward appearance of strength and tranquility is demanded in trainees, despite having minimal opportunities to get away from medicine and drop their guard. Lastly, taking actual steps to address mental health issues like depression can be very difficult. I have enough trouble finding time to get to see my family physician, I can't imagine what it would be like to get the time to see a mental health professional, especially for the kinds of regular visits that are often optimal for dealing with these issues. Medicine simply doesn't permit that kind of flexibility for trainees. 

As a result, many mental health issues are driven underground, which can give the appearance that it is far less common than reported in the JAMA study as well as similar reports. I've seen a degree of hostility towards even addressing these issues by students or residents who may not recognize the extent of the problem - in some cases, even by those who have trouble recognizing that they themselves are struggling with poor mental health.

There's also an unfortunate notion to dismiss cases of poor mental health in medical trainees as a problem with the trainees themselves. A lack of mental toughness or fear of adversity is often thrown around. Yet I've seen exceptionally strong medical students struggle. They might be doing amazingly well on evaluations or in clinical performance, but be unable to keep up with their social lives, personal interests, or even basic hygiene. Overall, medical students are already being carefully selected to be the most capable, resilient individuals available - if significant groups of trainees are having difficulty with depression, even if we had an outstanding admissions system, I doubt we're likely to get more resilient individuals who are also equally capable.

Addressing this problem is challenging. There are no simple answers as the depression is multi-factorial and any potential solutions to depression in medicine would encounter numerous barriers and trade-offs. I don't believe small changes are going to cut it, however. I think the stats seen in this study will continue until some fundamental changes are made to the way we train our physicians and, likely, the way we organize our healthcare system in general.

Bucket List

Too many serious subjects lately, time for some random non-medical musings!

So, I've been slowly working on my bucket list for the last few years. Not crossing things off my bucket list - I like to think I'm still young enough that I've got plenty of time for that - but what should be on that list in the first place. Anyway, here's what I've got so far!

(Disclaimer - I make no claim of originality in my bucket list)

1) Speak another language (or languages)
Like so many Ontarians, I took French in public school. I even took French Immersion, though I started in Grade 7 and finished up by Grade 11, so it was only 5 years of real exposure. And by "exposure", I mean less than half my classes were in French (sort of), so I never even approached fluency. At best, I could handle slow, conversational French.

These days my French reading comprehension is reasonable, but I have a lot of trouble listening to French and my ability to write or speak it is virtually non-existent.

I've always regretted not keeping up or improving my French - I am oddly jealous of people who can easily speak a second language. There's a mild practical side to this desire to speak French - there are a few career paths I've considered that would be opened up if I could speak French. None of them are likely at this point, but who knows?

If I ever nail down my French, I'd love to move onto some other languages as well. Haven't settled on which language - Cantonese, Spanish or Punjabi would probably be the most practical in Canada, though it depends a lot on location. Around where I live, Portuguese, Italian and Arabic probably have as much or more relevance than Cantonese. I'm leaning towards German - it's close enough to English that it shouldn't be crazy-hard to learn, has some international appeal (though many Germans speak English pretty well), and there is a large German-speaking population around where I'd like to end up practicing (but it's a unique dialect and they also tend to speak English pretty well). For shits and giggles I've also considered completely impractical languages like Finnish, a language with minimal similarity to other world languages confined almost entirely to a country where the majority of citizens speak English anyway.

2) Write a book
I like writing. I do a lot of work (well, unpaid work mostly) that involves writing in some format. I write a lot outside of work too. That's kind of what this blog is for - I write compulsively even without much purpose! At some point, I want to channel that desire to write in a longer, formalized product. Whether that's fiction or non-fiction doesn't really matter to me at this point (ideally I'd do both). Like this blog, I don't particularly care if anyone reads whatever book I write, so long as I can get it printed, bound and put on a bookshelf somewhere.

Non-fiction I think I could do without much difficulty. Every once in a while I pick up a non-fiction book by an obscure author presenting an interesting thesis. They're a bit hit-and-miss in terms of quality reading, but I can completely see myself doing something similar on any number of subjects. It'd take a lot of time, energy, and focus (none of which I have right now), yet beyond those issues, I don't see any major barriers to making a non-fiction book that I'd be happy with, even if it isn't a masterpiece of any sort. Could be a fun retirement project in 40 years.

Fiction would be trickier. I bounce around ideas for a fiction book pretty regularly, but general concepts are easy. Whenever I try to go a bit deeper and set some details on characters or plot, I hit a brick wall pretty fast. I'd set myself pretty high standards for a fiction piece, so that's part of the hang-up. I'm also not the most creative person in the world - ingenuity I think I have in spades, but tasks that require true creativity are a challenge for me. This could be more of a stretch-goal.

3) Learn to fly a plane
My one grandfather was never overly talkative before passing aay, so learning about his life was a bit tricky. But I do know that his time spent flying was a highlight of his life. He flew in WW2, though thankfully never went overseas. Instead, he flew bombers in Canada so the people actually doing the bombing could practice. I'd love to get a sense of what he experienced and why he loved it so much.

4) Learn to shoot a gun
This one I have trouble explaining. I've never laid my hands on a functioning gun. I don't see the point of gun ownership for any reason besides hunting. And I don't really want to hunt either. But, a few of my relatives shoot recreationally or hunt, including my other grandfather, so I'd like to at least learn the skill. Sort of a heritage thing I guess. Plus, I figure there are worse abilities to have if the whole world goes to hell (zombie apocalypse, anyone?)

5) Get to all 10 Canadian Provinces and all 3 Canadian Territories
Super-unoriginal here, but it's what I want to do, so it's on the list. When I was growing up, my family never did long trips to the common vacation spots, favouring camping and travel within Canada. I have so many good memories of visiting Canada and seeing what our country has to offer (or at least of playing Gameboy in the car while my parents saw what our country has to offer). So far, I'm 6/10 on the provinces and 0/3 on the territories. I'd like to fix that if possible!

Likes and Dislikes - Physical Medicine and Rehabilitation

I wasn't expecting to make another one of these posts, having finished my clerkship, but I did PM&R as a learning elective and feel it deserves a mention. Here's what I liked and didn't like.

1) Welcome to the Team

Medicine is a team sport and no specialty exemplifies that better than PM&R. Most interventions require follow-up or coordination with another healthcare providers, most commonly physiotherapists and occupational therapists. I was also impressed by the close interaction with prosthetic device manufacturers - who are typically privately-funded - in the management of patients with amputations, an obvious advantage for individuals whose lives are greatly affected by the nature and quality of their prostheses. It was also interesting to see the connections with other physicians. The PM&R physicians I worked with had a lot of their work referred to them by specialists, rather than by family physicians. This represents a somewhat unique position in medicine; while most specialists see a fair amount of their patients due to referrals from family physicians, community pediatricians, or emergency physicians, a large portion of rehabilitation work comes from neurologists or surgeons. Part of this disparity may have been due to being in an academic centre rather than general community practice, but even then, most of the academic physicians I worked with in the past nevertheless had their patients largely come from primary care physician referrals. Overall, this need to work with other providers meant a focus on communication and integration of service delivery. While there were still some hiccups, it was a refreshing attitude to see in medicine which so often has difficulties working together effectively.

2) I Forgot Stuff... Lots of Stuff

We learn about MSK problems and anatomy in 2nd year at my school. Shortly after, we learn Neurological program and anatomy. It's not hard to go through most of 3rd and 4th year using very little of that knowledge - of the core rotations, only Family and Emerg really draw on it to any real degree. As a result, my knowledge of these subjects has definitely... atrophied. I chose this rotation in part because I was fully aware of my ignorance on these subjects, particularly with respect to my neurology skills, but those first few days hit me hard - I have some studying to do before medical school is over!

3) Competitive

This specialty is going to be competitive this year, I have little doubt of that. It's a small field, with only 30 spots (almost entirely CMG spots) across the country, with no program having more than 3 spots per yet. Interest in the field is undoubtedly higher than that, significantly so. It's hard not to see why - it's a specialized field with a clear role and positive, observable impacts on patients; it has good hours, decent pay, open job market that's likely to expand; and a reasonable variety of clinical presentations and conditions with many opportunities for specialization. Somehow this specialty managed to fly under the radar for a long time. That's no longer the case - the match rate in PM&R took a steep drop last year and I expect this coming year will be no different.

4) Happiness Test

The best advice I got through my medical training is to go where the happy people are. PM&R docs seem pretty happy. They also seemed to maintain empathy better than most other groups of physicians I've met, and albeit with the odd exception, they seemed more grounded than most doctors I've met. Maybe it's their relatively lighter workloads and longer appointments with each patient. Maybe it's because they work with so many non-physicians on a regular basis. Maybe it's because their work is more oriented towards improving functional status than on treating illness. Whatever the reason, despite having zero interest in PM&R, in addition to little ability in the field, I thoroughly enjoyed my time on this rotation.

Considering Medicine - Prestige

We focus a lot on how students can prove they're good enough for medicine. These posts are for students wondering if medicine is good enough for them.

Short Version: Medicine a well-regarded profession. Most people generally assume physicians are reasonably intelligent and high-achieving. Perceptions of the profession are slowly changing, however, and not necessarily for the better. More importantly, prestige essentially represents the opinions of others based on superficial qualities and only matter to the extent that those opinions are valued. Prestige in a career is often most meaningful to those who feel their job lacks prestige. As such, its main value is in assuaging personal insecurities, but it can only do so much on that front. Having a prestigious profession is no substitute for developing strong personal self-esteem.  At the end of the day, prestige is a hollow comfort if a physician does not find the actual work of their job satisfying.

Long Version: Humans are social beings. We intrinsically care about what others think of us, even when those opinions fail to represent reality. It is in this light that we should consider the prestige of going into medicine.

The majority of individuals have positive opinions about physicians. In multiple polls, medicine is still regarded as one of the more respected, ethical, and trustworthy professions. Physicians tend to be thought of as intelligent and hard-working. Becoming a physician is often thought of as an achievement in isolation. Being a physician has many of the trappings of prestige, of being though of positively by society - with the "Dr." title, high pay, often an office, many times physicians get additional awards, or honours, or academic appointments.

It is hard to deny that medicine is a prestigious profession. Yet their are some cracks in public perception of physicians. With high earnings, physicians' earnings are coming into question, with concerns about the value the profession places on money. As medical knowledge disseminates more broadly, the expertise of physicians is more frequently under scrutiny by patients. Moreover, physicians can be seen as cold or uncaring when failing to meet the typically high expectations of empathy. If physicians ever were implicitly trusted because of their profession alone, that time has long passed.

What often gets lost in conversations about professional prestige is that while professions may have general qualities, they're made up of individuals. Individuals have their own qualities which may adhere to or contrast with those of their profession. For example, a physician isn't intelligent because they're a physician - they're intelligent because what they have acquired a good base of knowledge and the problem-solving skills necessary to use that knowledge effectively. The vast majority of physicians are intelligent, having the mental faculties to make complex clinical decisions competently, but there are exceptions. Becoming a physician doesn't instill intelligence automatically and as a result, a small minority of physicians are not particularly bright. Likewise, choosing to not become a physician will not remove intellect from an already-intelligent person.

So why should prestige matter at all? Well, it gets back to that original question - we care what others think of us. Furthermore, we want those positive opinions of us even when we don't have the time or opportunity to demonstrate our true qualities. It's not feasible or socially acceptable to demonstrate your level of intelligence to every person we meet. Our careers provide a proxy for who we are as people, whether we think that proxy reflects who we are or not. Being a physician provides a benefit of the doubt other professions often don't.

That benefit of the doubt can be a small comfort, however, when knee-deep in the medical profession. If there's one group of people unimpressed by someone being a physician, it's other physicians. In medicine, particularly in the training phase, guess who you'll be spending most of your time with? Likewise, most of the non-physicians you work with won't be overly impressed by your job. Nurses, pharmacists, PSWs, RTs, and the gamut of other healthcare workers have been around physicians long enough not to be in awe of the title. They will generally like you as a physician if you work well with them and do a good job for your patients, but will never like you because you're a physician.

The bottom line is that a prestigious career provides some benefits in terms of how you're viewed by others, especially those who don't know you well. When choosing a career based on prestige alone, you could do much worse than medicine. Yet, prestige is a weak and inconsistent shield against the judgments of others. Not everyone views physicians in a positive light, particularly those in regular close proximity to physicians. Therefore, as with any career, having the self-esteem to recognize who you are as a person, independent of how your job is viewed, is vital. If you don't have the confidence in your own abilities or value, being a physician will not provide much help to assuage those feelings. Similarly, if you do have confidence in who you are, that will show through regardless of what your career happens to be.

In the end, I believe that the prestige of the career is a positive reason to become a physician, but an exceedingly minor one. If a physician enjoys their work and the other aspects of medicine, the prestige of medicine is a helpful perk. For those that aren't as thrilled by the job itself, prestige is a poor consolation prize.

CaRMS In

After much scrambling, managed to complete my CaRMS applications on time. Personal letters got done at the last minute and I submitted everything far later than I'd like, but it's all in. My letters of reference were received in good time and all assigned already, so I don't even have that second reference letter deadline to worry about. It's all in, complete and done.

Posting has been a little bit delayed and will likely stay that way as I catch up on missed sleep, but it feels great to have a bit of extra time to get back to blogging. Expect to have some meatier posts in the near future.

CaRMS - Deadlines Approach

Ok, so I have to finish my CaRMS applications by this Tuesday. I've picked my programs, my letters of reference are all arranged, and most of my documents are uploaded. I've still got quite a bit to do this weekend, however. I have one personal letter that still needs some final edits and another three that need to be written.

I'm starting to over-analyze those personal letters a bit, and it's getting to the point where I really wish my brain would shut up. I'd like to think my application is fairly strong, but this is when the uncertainty creeps in. So, I'm going over trivial differences in wording and obsessing over what content to emphasize. It's going to be an exciting weekend...

Nevertheless, it feels good to be at this stage and to have everything put in. I'm confident in my interviewing skills, and while I won't be leaving anything to chance their either, once my written applications are in, I'm over what I consider to be my last major hurdle in my residency applications. Well, assuming those go well and I get the interviews I'm hoping for - we'll find out in a month or two!

So, About Last Tuesday...

I'd feel almost neglectful if I didn't touch on the US election last week. This blog is primarily about medicine and healthcare, so my intention was to touch on the numerous effects a Trump presidency is likely to have on the health of people in America as well as those abroad. However, since starting this piece, both major media outlets and more healthcare-focused sites have provided analysis of this with various degrees of depth, and I'm not sure I have much to add. Fortunately, the effects are fairly easy to sum up without losing too much with the brevity - a large number of people, mostly poor or sick people, will lose their health insurance or will end up with less-comprehensive coverage.

Of course, health effects will depend on exactly what policies Trump choose to enact, whether unilaterally through executive action, or through legislation by working with Congress, so it's hard to say exactly what will happen. Nevertheless, the proposals presented thus far all lead to that somewhat over-simplistic conclusion above according to multiple independent analyses.

It's a striking reminder that health depends on so much more than medicine. The sum of medical knowledge and ability in the US is constantly increasing, but the health of its citizens is likely to worsen if Trump proceeds as promised during his campaign. Keeping engaged in the political process and involved in advocacy roles are both important ways for physicians to influence the wider society that has far greater effects on patient health than most physicians' direct actions.

Like many disappointed by Trump's victory, I take this result as a spur to action. No, I'm not American, but it's a reminder that undesirable outcomes are often the result of complacency and that to see sustained progress, sustained effort is required. While I do use this blog as a way to express my viewpoints openly and honestly, I would like to make a more concerted effort to be directly involved in how the world is run around me. That said, as we see protests spring up across America, I'm equally reminded that hate is not the answer to hate. Most of the protests are peaceful, but some are not, and violence cannot be the answer even when other viable options are available.

Lastly, I'm reminded that effective advocacy should be one of the final steps to enacting change, not one of the first. Before pushing for what we think is right, it's vitally important that we take the time to determine what right is. Too often, advocates assume their positions are correct without ever challenging their own viewpoints, and good intentions are no substitute for a considered, informed opinion. Reading, listening, and learning are essential before - and after - speaking out. That includes
paying attention to those viewpoints opposed to yours. Those opposing views don't need to be accepted, but they should at least be understood. Furthermore, when asking the world to change, we first should consider how we can change ourselves. No one's perfect and that's an unrealistic goal, but there is always something we can do to change our actions and behaviours to do further our own priorities for the world.

I do a lot of my advocacy through this blog and other online postings. It's not a particularly effective approach - those who come to the read the blog are typically sympathetic to my viewpoints already, so I'm largely preaching to the choir. So, I feel the need to take a few more direct steps. My first is by starting some regular charitable contributions to causes I care about, putting my (currently limited) money where my mouth is. My goal has always been to give a significant potion of my income to these or similar charities, so despite my growing debt, I might as well start now, as I'm finally on the verge of having a real income. While I've always been involved with school projects that I feel are meaningful, I'm going to try to spend my last year and hopefully my residency as well, with more direct involvement in the curricular side of medical education. Lastly, I'm looking into ways to be involved in the political process. I'm not sure what form that will take, as I'm not particularly partisan and not sure how I feel about joining any political party, but it's time I explore my options. Staying on the relative sidelines, where writing and voting are my only methods of influencing policy, just doesn't feel like enough at this stage.

Considering a Career in Medicine - Money

We focus a lot on how students can prove they're good enough for medicine. These posts are for students wondering if medicine is good enough for them.

Short Version: Once established, a physician in Canada can expect to make a solid six figure income, with significant variation based on specialty, location, and practice type. However, it takes quite a bit of time and debt to become established. As such, delays in financing typical life goals are common. Money management skills are necessary to financial security, particularly when considering retirement, as physicians face different financial considerations than most individuals. Physicians often find themselves in trouble when they fail to control their spending habits and adequately save for the future. The high income in medicine is often a result of long hours worked, not just high hourly wage. Lastly, any career path should be considered with alternatives in mind, as students may have other, equally lucrative options.

Long Version: A desire for money is often thought of as an unsatisfactory reason to get into medicine, but money matters and income is an important consideration when planning a career. In Canada, physicians' income is high relative to most other countries, with the notable exception of our neighbours in the United States. There is significant variation in incomes for physicians. Specialty is the greatest factor, with lower-earning specialties like Psychiatry, Family Medicine, and Pediatrics earning closer to $200,000 on average, while high-earning specialties like Radiology or many surgical specialties earning in the range of $400,000 or higher. These figures are after accounting for overhead, but before taxes. Within each specialty there is a range of incomes as well depending on location, type of practice, and commonly performed services. It is not uncommon for practitioners to earn more - sometimes significantly more - than the averages quoted above.

Put simply, physicians have very good incomes, reliably putting them in or near the top 1% of earners in Canada. This high floor on earnings does come with a relative ceiling on income, however. Whereas similarly high-earning professions like law or business see elite performers earn several times what the average person in their field makes, physicians do not see that degree of stratification. The public healthcare system rewards quantity and with limited numbers of hours in the day, there's only so much physicians can do to see more patients and thereby increase their income. As a result, it is quite rare for a physician, even one in a high-earning specialty, to net over $1 million per year. Physicians are high earners, but students should not be expecting obscene levels of wealth.

Timing is also important when it comes to income and overall wealth generation, as the financial benefits of being a physician are not realized until after completing a long period of training, typically while accruing a fair amount of debt. A 40 year old physician tends to have more financial freedom than their peers in other careers. A 30 year old physician usually doesn't. This can complicate the achievement of non-career life goals that tend to occur in a person's late 20's or early 30's, such as buying a house, getting married, or having children, all of which carry a significant expense. All of these milestones are achievable as a medical trainee or recent graduate, but compromises are typically necessary. Some events will be delayed. Others will be lessened in scope - a smaller house, or a more modest wedding ceremony. Still more may be achieved only through added debt. Early career aspirations may need to take a back seat to income-generation. Over their career, physicians earn plenty of money to justify the initial time and debt invested, but the payoff is later in life, not earlier.

Once established, physicians' finances get easier in theory, but in practice, many continue to struggle. Physicians are notoriously poor money-managers and it can get them into serious financial difficulty. A mid-career physician has an enviable income, but can often set themselves up to have equally high expenses. After years of hard work and sacrifice, many physicians fall into the trap of spending too much and saving too little. This is particularly important as the vast majority of doctors do not have an employer-provided pension, meaning significant personal savings are required for a comfortable retirement. Jobs in medicine do not tend to have benefits either, residency being the notable exception, so physicians must also manage that expense out of their income. Failure to properly prioritize expenses through careful budgeting can leave physicians with significant money-related stress, despite having ample resources.

It should be kept in mind that the high earnings in medicine tend to come with long hours. Overall income can seem a lot less impressive when put in terms of an equivalent hourly wage, particularly once taking account all the unpaid aspects to a career in medicine. I hope to expand on this more in future posts.

Ultimately, when considering a career from a monetary perspective, a comparison must be made to alternative pathways, which can vary wildly person-to-person. If a student leaves undergrad with strong career prospects outside of medicine, they'll likely get far less of an overall gain from going to medical school than someone graduating their undergrad with zero immediate job prospects. In rare cases, going into medicine can be a financial negative. All students considering medicine should be actively developing alternatives to becoming a physician and should make the decision whether or not to enter medical school in light of those alternatives. Medical students tend to be intelligent, hard-working, communicative individuals who could be successful in a number of careers aside from medicine - it shouldn't be assumed that becoming a physician is the optimal choice from a monetary point of view, though it is often the lowest-risk pathway to ensure a six-figure income.

To sum up, there are some strong financial incentives to consider medicine. A physician can expect to be well-off to outright wealthy, but there are some caveats and physicians do need to budget their expenses to maintain financial security. Proper planning, with realistic expectations, is critical.

OMA and Elections

The Ontario Medical Association is not popular. It hasn't been for quite some time - speaking with senior physicians, I seem to find no one who has nice things to say about the OMA as an organization - but the feelings towards the OMA seem to have declined even further since the tPSA debacle. It provided such a clear example of animosity between the OMA and its members.

The OMA has gone on a massive "reconciliation" drive, soliciting opinions from members and hosting meetings across the province. While welcome, these efforts seem to only underline that the OMA has no idea what matters to physicians, residents, and students, or what the situation is like on the ground for its members. There is continued skepticism that this effort will not lead to meaningful changes in how accessible the OMA is on a regular basis, how it operates, or how it makes important decisions such as negotiating with the province over physician funding. Frankly, much of the communications coming out of the OMA since the tPSA vote have been rather underwhelming, jumping between irrelevant to my situation, or well-intentioned but pushy (a recent advocacy drive fills my mailbox more than I'd like)

That's why I was pleasantly surprised to see a recent e-mail regarding OMA elections. I've now been an OMA member for 4 years. I have no idea how the OMA's leadership is chosen. I've voted in a district election a few times, but don't understand how the candidates I picked between were chosen, or what their responsibilities are. I've tried looking once or twice and came up short. I'm sure the information is somewhere and if I put in a concerted effort, I'd find an answer and ultimately, it is on me to be informed as to how the institutions I'm a part of run, but democracy - even in the confines of a private group like the OMA - shouldn't be that hard. Physicians are busy and can't devote endless time to wade through the intricacies of a group that is supposed to be representing their interests.

This lack of accessibility and transparency was certainly part of the frustration with the OMA in recent years. The OMA hasn't seemed accountable for its actions and the only way to get a say in the process seems to require significant individual effort, usually with little effect. One of the arguments from the OMA and OMA-supportive affiliated groups was that the tPSA had validity because it had been approved by democratically elected OMA representatives. When OMA members don't feel as though they had much say in any election, or that their representatives, well, represent them, it doesn't give much credence to the OMA's argument of legitimacy.

The election changes appear to move the OMA towards transparency and simplicity. Elections seem to be easier to participate in as a candidate and to vote in, with fewer barriers to being a nominated candidate, consolidated elections, and online voting. It's a small step. Probably not a big enough one. I'm skeptical this will provide enough benefit to truly reform the OMA's ability to engage with its members. Still, after a rash of empty promises or tone-deaf announcements, I'll consider this a positive change and leave it at that.

Advising Highschoolers and Undergrads on Medicine

If you're in high school or undergrad and interested in medicine, it's not hard to find opinions on whether you should pursue becoming a physician. Parents will weigh in, mentors will weigh in, classmates and friends will weigh in. Critically, physicians have their own views on whether prospective medical students should become doctors, and they tend to share those opinions, liberally. It is not difficult to find those viewpoints online or in print.

And those viewpoints are diverse. Very diverse. On one hand, which gets promoted by universities and physician organizations, you have the physicians who feel that medicine is a wonderfully unique career, that they derive immense satisfaction from, which is worth considering and striving for. On the other hand, which more frequently comes up in anecdotes of prospective medical students who have asked physicians they know about the field, is the notion that medicine will suck your life away with all its demands on your time and energy, and thus should be avoided like the plague.

So what's a potential future physician to think? Is medicine an incomparable opportunity for success, or a dangerous trap leading to unhappiness?

It'd like to come out and say the truth in somewhere in the middle, but I'd say it's more like it's both at once. It's undeniable that medicine provides many opportunities - both personal and professional - that are not easy to come by in other fields. Already, I've had the chance to see and to do and to experience more than I likely would had I stayed in my previous career. I have new perspectives I never would have experienced in any other profession. Yet, I've also had to give up a lot of things I care about to continue on in medicine, more than once going through long periods of exhaustion or being overwhelming, experiencing despair bordering on depression.

My expectations for life have been revised upwards in many ways, while being simultaneously revised down in many other aspects.

That may sound bleak, but I don't view it that way. Life is about making choices, and those choices come with consequences, both good and bad. We can't take advantage of every opportunity - our time and energy are limited. Going into medicine was a choice that has had some positives, some negatives. Some of these trade-offs I was aware of heading into medical school. Others I knew about, but failed to fully appreciate. Still others seemingly came out of nowhere.

When a physician gives a judgment on their satisfaction with their career, or their views on medicine as a vocation in general, they tend to be giving a summary opinion on those trade-offs, perhaps highlighting the good or bad aspects that matter to them the most in forming that opinion. Yet its digging into the trade-offs that the answer becomes clear and each person will place different value on the pros and cons of the profession. To make matters more confusing, as people grow over time and experience new elements of the profession, their viewpoints will change - my own verdict as to whether going into medicine was the right choice or not has jumped around multiple times and continues to do so, even after 4 years of medical school.

So, should a student considering medicine take the plunge? Maybe. It depends on a number of factors, including current situation in life, career alternatives, life goals or priorities, and personality. Making any career choice is too complex to put into a binary "yes-or-no" answer and apply it to everyone. That's doubly true for medicine, a field with significant sunk costs and limited opportunities to smoothly transfer to another career (especially early on). Sorting through the meaningful considerations is well beyond the scope of a single blog post, and should ideally involve an active conversation rather than passive reading.

However, recognizing that not everyone has a physician they can talk to in-depth about all aspects of medicine, I think it's worth having some general information available on what a student can expect from a career in medicine. Over the next little while in a series of posts, I would like to explore some of these factors in greater detail. I can't provide a full weighing of preferences, but perhaps I can provide some context.

Halloween

Today is Halloween! Well, when I wrote this it was Halloween, as of the posting time, yesterday was Halloween!

The hospital embraced the day, with so many employees dressed up. The pediatrics department, as usual, stole the show. Got to see a kid in a Minions costume! The facilities staff also stood out, a lot of very interesting (and surprisingly functional) costumes around.

I'm on a Psychiatry elective, which means dressing up is generally frowned upon. Tame costumes in appropriate circumstances only. Some of the patients got into the spirit though, which I just think is awesome. Definitely brightened up my day.

Anyway, here's hoping you're having (err... had) a good Halloween!

Beyond Pharmacare

It's more bubbling under the surface than being a headlining issue, but national Pharmacare is steadily becoming a major point of conversation within the medical community. Most countries with universal healthcare include some form of provision of pharmaceuticals, if not outright coverage - Canada is the notable exception. As such, Canada has now become a patchwork collection of private insurance, industry-provided samples or give-aways, public welfare programs, and out-of-pocket purchases in order to provide these drugs to patients. It's not a particularly efficient approach, with high costs for patient health, economic prosperity, or even balance sheets for government agencies.

What gets lost in the conversation is that when it comes to healthcare coverage in Canada, it's not just drugs that get the short end of the stick, it's most therapeutic interventions. Big, hospital-based treatments - surgeries, inpatient stays (including medication), dialysis, etc - are still covered, but non-pharmaceutical outpatient therapies rarely get adequate funding. The two that spring to mind most readily are physiotherapy (PT) and mental health therapies, notably Cognitive Behavioural Therapy (CBT). PT is a main component of treatment for most non-critical musculoskeletal injuries and in many cases, may be the only or main component to effective treatment. CBT is the first-line treatment for most cases of anxiety (which is exceedingly common) as well as a component in many other mental health treatment plans.

There are now some funded programs for both PT and CBT, but they naturally have long wait-lists. As a result, the rest falls on private insurance and out-of-pocket spending. The concern, as with medication, is cost. PT and CBT both involve having a qualified healthcare provider spend significant time with a patient. In-person contact is expensive and the public healthcare system is understandably hesitant to provide coverage, particularly if these treatments need to go on for some time.

In most cases though, neither PT nor CBT should go on for an extended period of time. PT and CBT have primary benefit when they teach patients exercises or skills to deal with their conditions. A single PT appointment may be enough in mild cases. CBT requires a few more, but a short course is often sufficient if the patient is compliant and motivated. There's always the possibility of therapy needing to go on longer than intended - but the same can be said of medication.

I'm very hopeful that Pharmacare becomes a reality - I've already seen far too many patients struggle with getting necessary or helpful medications. No doubt more fail to get important medications without their healthcare providers being aware, as research on compliance with medications in the setting of economic difficulties makes absolutely clear. Yet, as coverage for medications expands, I do worry about these outpatient-based, non-pharmaceutical therapies falling by the wayside, especially when these interventions are often more effective than pharmaceutical alternatives. Looking towards my future practice, I find myself taking a decidedly "drugs if necessary, not necessarily drugs" attitude. I want a public insurance system that supports such an attitude.

Problem-Based Learning - A Follow-Up

I'm of the viewpoint that you shouldn't criticize the actions of others without having a reasonable alternative to offer. I'm not a fan of traditional lecture-based medical education, and just wrote a post against one of the more popular alternatives in Problem-Based Learning (PBL) curriculums, so I should probably provide some sort of third option.

Lectures, PBL, any other approach in education is simply a tool to transmit information. Like any tool, they can be used effectively or ineffectively. Hammers work great on nails, not so much on screws. Lectures are amazing at conveying large amounts of information quickly to large groups of people. However, unless an instructor is particularly capable, lectures are terrible for information retention. PBL is great for information retention, but terrible for information transmission. Used in conjunction, these approaches can maximize efficiency in education. Introductory information is conveyed via lectures in bulk, then emphasized and expanded upon with appropriate problems.

Many schools employ some version of this combined approach, but not necessarily in a well-constructed manner. Sometimes one technique is relied upon too heavily. Sometimes the timing or coordination is problematic, such as providing a PBL task before a lecture, or so far after it that retention from the lecture is minimal. Deliberately using both techniques together, as two parts of a whole, is preferable.

In reality though, the tools themselves are flexible and can be adapted to account for their weakness. Lectures can be interactive and entertaining, maximizing retention. PBL can provide concise supporting resources, or have knowledgeable instructors available to provide context and guidance. Yet achieving these adaptations is easier said than done. Strong lecturers are surprisingly rare. Having adequate numbers of instructors for PBL for an entire curriculum is expensive. As such, combinations of approaches may permit less-than-ideal versions of these tools to be sufficiently effective given basic resource constraints.

If I were designing an educational approach from scratch, my emphasis would be on the basic points of educational psychology that too often get neglected - scaffolding, context, and repetition. Clinical education is so effective because it naturally includes all these elements. Pre-clinical education is often so ineffective because it fails to incorporate them. Repetition in particular is sorely lacking.

My preferred structure for medical education would be based around repetition. If a piece of information isn't conveyed at least three times within the span of a month or so, to me, it's not even worth teaching, at least not at such an early stage as during pre-clerkship years. I would like to see another tool, one which has a good evidence base behind it, used more frequently - formative assessments. Formative assessments are wonderful because they eliminate the pressure for short-term learning seen in summative assessments, while providing an opportunity to identify gaps in knowledge.

So here's my ideal set-up: in the first week, lectures, small group discussions, or readings would be given on a set of associated information. This transmits the information. The second week, a formative assessment is given testing all the transmitted information. This assessment is taken up with students to identify class-wide and personal gaps in knowledge. The third week, an applied, context-heavy session is held. This could be PBL, Team-Based Learning, physical skills instruction, anatomy lab, or really anything that requires some application of the knowledge outside a classroom setting. Ideally, this would adapted to the weak points in class' knowledge based on the formative assessment. Four-to-six weeks later, a summative assessment is given to test the students' knowledge, forming the basis of the students' marks. Even though this is a graded test, the results of the test should be given to the students to identify any remaining deficiencies in knowledge. Evaluations are necessary, but they're also one of the best ways to learn, and I've never understood why schools place such a high priority on keeping test answers secret. Yes, I know they want to keep future classes from just studying the questions on the test, but it's a poor excuse. Either schools are failing to ask a wide enough variety of questions on their tests (question bank is to small for the amount of material provided or they're recycling a limited number of idiosyncratic questions), or all the pertinent information is in those questions they're asking and in that case, who cares how students learn that information - that means they're getting all the necessary data!

The main weakness to my approach is that it's a bit more time-intensive for each fact that gets presented. You can't give nearly the same number of lectures if you're losing a day or two each week to formative assessments or application tasks like PBL. I strongly believe this to be a worthwhile trade-off. While less information is provided to students, more should be retained. More importantly, what information is retained should be more consistent student-to-student. Consistency matters when setting expectations for subsequent steps, such as in clerkship. I found it baffling that I could know nothing about a part medicine that I learned about in pre-clerkship and no one cared - what was the point of those first two years if I could start right back at the beginning without consequence? What I did remember of course came in handy, but what I retained from pre-clerkship and what my colleagues retained from pre-clerkship was at times shockingly different. Clinical instructors have to set the bar very low when there's such variability in learner knowledge.

I'm starting to ramble, so I'll try to wrap this up. In medicine, clinical education will always be the most critical aspect. I've argued before that we should substantially reduce pre-clerkship education, or even scrap it entirely. However, realizing that clinical educational opportunities are limited and that having some base knowledge before seeing patients helps protect both students and patients, I doubt we'll ever eliminate pre-clerkship education. So, if it must exist, I think it could use a revamp, to become more efficient, more effective, and for its results to be more consistent. It doesn't take more money, or more time, or fancy educational innovations. It just requires some variety in instruction techniques and a focus on applying the basics of educational theory thoroughly.

Problem-Based Learning

One of the new trends in medical education, particularly in the US, is Problem-Based Learning or PBL. PBL posits that letting students explore topics openly, with goals and guidance rather than tasks and obligations, will lead to greater investment in learning by students, as well as overall better retention of knowledge. Extending on this idea, PBL often involves students working in teams - Team-Based Learning or TBL - to allow students to share knowledge more freely and to work collaboratively towards a solution.

In theory, PBL addresses a lot of the objections I have to the current "standard" approach in medical education, particularly in pre-clerkship. I find the lecture-heavy, test-based format I went through to be rather inefficient and puts students in a fine position to burn out or put in a token effort. Yet, I'm very skeptical of PBL, particularly TBL, in the way many schools seem to want to use it.

Central to my concerns with PBL is that to solve a problem, you first need the tools and knowledge to do so. Giving students the freedom to choose an approach, or putting them in groups to work together, does little to overcome any gaps in necessary knowledge students inevitably have when training to become a physician. PBL proponents will argue that having students explore to find that background knowledge helps retention - and undoubtedly it does - but it's also very inefficient unless students know exactly where to look for that information. For example, it's very important for students to know the first-line treatment for simple UTIs. It's basic knowledge anyone who's finished clerkship should be able to pass along. Yet, if you were to search for that information, you'll quickly get about a half-dozen different answers, all of which are partially correct, but picking out the standard conventional answer is impossible without being given some actual instruction by a knowledgeable person. A naive learner simply won't have the context necessary to discriminate between imprecise recommendations available. The freedom to explore an answer - or the benefit of collective thought - simply doesn't contribute in the way guided instruction would.

Once all the necessary background information has been learned or provided, PBL works great at putting it all together. Moreover, putting all that knowledge together can help with retention of those facts. TBL can further enhance this by letting students fill in each others gaps in knowledge, since no student gets everything right 100% of the time - even the best students forget something.

Unfortunately, the goal of pre-clerkship is largely to give students that background information. Putting it together is left for clerkship, which essentially functions like a natural form of PBL. Clerkship has the additional advantage of authenticity, an often-overlooked trait when trying to motivate students to work. For all its promise of enhanced student engagement, PBL suffers from much the same drawback as traditional instruction - goals are set by the program, not by the student. PBL becomes just a different hurdle to jump over to move onto the next step. The motivation to do well remains extrinsic, even as engagement increases. In clerkship, the presence of an actual patient to empathize with - and the fear of disappointing preceptors invested in their patients well-being - provides some intrinsic motivation.

PBL and TBL can have an important role in education, particularly medical education, but their use needs to be tailored to their strengths. These techniques should be used to solidify knowledge already learned, not to teach new information. Most importantly - and proponents of PBL are quick to advocate this - instructors should be readily available to provide context and direction, as both PBL and TBL can quickly become troublesome if students' thoughts veer away from the correct path. As much as possible, PBL should be used where students already have motivation to learn, should be evaluated in a formative manner, and ideally the topic should involve some choice from students. PBL is a great tool, but it's not a panacea - it should be used where it's appropriate, and discarded where not. My experiences with PBL and TBL thus far have made me worried that educators might not understand where these tools are best employed.

Familiar Faces

Unlike most elective students, I'm doing a good number of my electives at my home school.

Part of this was by design - as a student applying primarily to Family Medicine, I don't need to do nearly as many electives in one field, so I've got some extra elective time to spend on learning opportunities, on rotations I haven't experienced yet first-hand. Those can be done anywhere, so might as well do them in a familiar setting where I don't have to pay for travel or accommodations. Plus, I can spend more time with my partner and dog at home!

Part of this was definitely not by design - I had some electives at other schools fall through last-minute after months of waiting. Just a reminder that despite the new electives portal in Canada that is supposed make electives more accessible and to eliminate the need for elective-hoarding, there's still a major incentive to gather up as many electives as possible, dropping any excess ones as you go.

One unexpected advantage of this arrangement, however, is getting to see some patients I saw previously on my third year rotations. Seeing a familiar name, or stumbling across a prior dictation with your own name on it is pretty exciting! (Side note - dictation services do a pretty good job. Recently read a note I dictating very early in clerkship and superficially, it looks amazing! When I actually read the content, it's fairly disorganized and rambling. It does its job, but I feel I can do so much better at this stage and it only looks half-decent because the dictating service my hospital uses made it look that good).

This is not necessarily a common experience in medical school. We get shifted from service to service regularly enough that any continuity within these services is pretty short-term. Seeing a patient after 2 months isn't quite the same as checking in on them over a year later, but this longitudinal care is a core part of being a physician. Even as just a reminder of the growth we go through as medical students, I'm appreciating the experience. I know some schools, particularly satellite campuses, have been working with clerkship models that build these sorts of longitudinal experiences into their structure, and US schools having been piloting studies on longitudinal clerkship for years. From speaking to some people in longitudinal medical education programs, I've been given the sense that these set-ups are better in theory than in action, but there is some interesting research on the subject. Given my recent experiences, I would love to see effective longitudinal care fit more cleanly and reliably into undergraduate medical education.

Moving Up the Totem Pole

I'm now on my 4th elective, but it's my first one in a hospital setting after several rural or exclusively clinic-based electives. That means, in addition to triggering some lingering anxiety about hospital work, that I'm working with some 3rd year students. For the first time in my medical career, in a clinical setting, I'm not the low man on the totem pole.

As I'm a still a medical student, my role has not appreciably changed and the expectations have only increased marginally. However, it is a very different feeling, having that extra year of experience in medicine and, because I'm doing an elective at my home hospital, familiarity for the system I'm working in. It is a far less stressful set-up than 3rd year.

I'm also being given some authority and responsibility over my slightly-more-junior colleagues. I get a very small amount of control of the daily schedule as a result, which provides an amazing sense of liberty after a year of having zero control. I get to do a little bit of teaching, which I love - wherever my medical career takes me, I would like to be teaching for at least part of it.

Despite my supposed seniority, what has struck me is the capabilities of the 3rd year students I've worked with. Maybe I'm just meeting the best and brightest, maybe I didn't give myself enough credit back when I was a 3rd year, but they seem a lot more able than I felt back when I was in their position. In short, I'm impressed. I still have some information to pass along - I didn't get through that whole year without learning something - but it's not as wide of a gap as I thought it would be by this point!

Bureaucracy

The fourth year of medicine is pretty good. You get a fair bit of choice over what you do and where. You get less call. There's no block exams and evaluations are considerably less stressful.

Where fourth year (and the process leading up to fourth year) is terrible is in its bureaucracy. Medicine, as a rule, is organizationally complex, which leads to a number of rather problematic inefficiencies. Today's fun bureaucratic hurdle is registering for the MCCQE Part 1. It's an important exam, without a doubt, the only standardized test we take in medical school. It's also part of our licencing.

As part of the registration process, the Medical Council of Canada (MCC) requires identification. Completely reasonable, this is a non-trivial test that is one of the few milestones we insist on to ensure potential physicians are sufficiently knowledgeable. Any cheating in the form of impersonation would be a serious concern. So, they have a fairly stringent requirement - a notarized copy of a current passport. It's a bit specific since not everyone has a passport, and many other valid forms of ID exist, so I wish they would be a bit more flexible in what documents that would take. However, in my case, I already had my passport notarized for CaRMS, so I can reuse it for the MCCQE Part 1.

But wait! Apparently a notarized copy of the document that gets me into other countries isn't good enough for the MCC on its own! They also insist on a separate, MCC-specific form, with two passport quality photos attached and to have that notarized as well. Why? No clue!

So, now I need to get more passport-quality photos, fill out this needless form, and get it notarized. My school is kind enough to have notaries available, but of course, they're only available during regular working hours in my school's city. Not terribly convenient for fourth year students on elective across the country who, even with the nicer fourth year schedules, are still never going to be available during regular office hours without taking time out of electives. I could have had this completed at the same point I had the passport notarized, but of course, had no idea this was a requirement and was never informed of the requirement by my school despite this happening every single year.

Sadly, situations like this occur frequently in medicine and cause numerous headaches for providers, patients, and families. This is just a taste, but it follows a familiar framework. We've got multiple organizations who are not co-ordinating well on a task that is a joint responsibility, with one organization putting up needless hurdles and the other failing to anticipate challenges in overcoming those hurdles. As a medical student with my future career on the line, it's extremely annoying. I can only imagine how patients feel facing similar circumstances with their health in the balance.

Bad Habits

Everyone has a few bad habits. These poor habits can be a significant drain on health and on quality of life. I think it's worth touching on one of mine as a follow-up to my previous post.

I get way too much screen time. I spend way too much time on my phone, computer, or watching TV. I'm on a primary care pediatrics rotation where I frequently talk about appropriate screen time for children (< 1 hr per day) and I can't help but feel like a huge hypocrite. The last time I got less than an hour of screen time in a day way probably back when I was a teenager and was camping out in the middle of a lake miles from any electronics.

Screens have become part of life for most people, so I'm hardly unique here, but my average day is probably about 75% screen time, if not more. It's a problem and one I'm definitely going to have trouble breaking. Realistically, I'm never going to be completely screen-free. I use screens for work, for school, for studying. It'd be impossible to function without screens in those situations.

However, there's a number of ways I can and should be cutting back on my screen time. First is with TV. I watch too much of it. I watch it reflexively. Don't even care if there's nothing on I want to watch, the TV is often there as background noise. We don't pay for cable either, so it's all Netflix or other streaming, not even something like the weather network or news.

Second is in keeping up with the world. The internet is great for getting news and discussing current topics, but it's also unbounded in these regards. There's always another viewpoint, another topic, another article that can be read. And I binge on this stuff. I don't think I'll ever stop this obsession with how the world works - it's part of why I went into medicine - but I would like to take some of these activities off-line. Once residency starts and I have actual money to spend, rather than a line of credit to increase, I'd like to start getting some print media sources. You know, actually pay for the information I get. If I can't break my information addiction, I can at least save myself some eyestrain while satisfying it.

Last and certainly not least - gaming. I like video games. And I have a history of video game compulsion if not outright addiction. I've probably spent about 10% of my total life - including time spent sleeping - playing one video game or another. My Steam collection has me at about 100 days of total playtime, which isn't too bad on its own, but neglects almost all of my major time-sinks. With certain games, I can waste an entire day without even realizing it. In the past, I've wasted far more than a day without realizing it. Sometimes days like this are benign or even helpful - a day off every once in a while is hardly a bad thing! But when it happens too often, happens when I really can't afford a day off, or happens without being planned, it just leads to more stress. Gaming is basically a hobby, and I need to be treating it like one, with regular, scheduled, and non-intrusive times set aside for it.

Getting more exercise and eating better were hard changes to make, but I think I've made a good start down that path. Cutting down on screen-time is going to be much, much more difficult.

Lifestyle Modifications

One of the things I've enjoyed about Family Medicine is that it's really the one area of medicine - aside from perhaps Pediatrics - that can get patients to start living healthy lifestyles before they develop disease. It's not a common occurrence - I've really only had a few patients come in where they were truly in a pre-disease state and could have their risk profiles change with lifestyle modifications - but in a medical system that is still primarily reactive, it's a valued opportunity.

For all our medical advances, nothing beats a healthy lifestyle to ensuring continued well-being. A balanced diet, sufficient exercise, adequate sleep, stress control, elimination of smoking, and moderation of drinking. For most patients, these six habits will do more to provide a long, happy life than anything any physician can provide.

These interactions have also been a great reminder to put the emphasis on my own health. Over the past two years, my health habits have fallen to pieces. I went from getting regular high-intensity exercise to getting virtually none. My diet went from reasonable-to-good to consisting of a lot of sugar-heavy foods. I started getting less and less sleep, of poorer and poorer quality (call and 5:30 am shifts didn't help much with this). Stress was naturally through the roof during clerkship. On the plus side, I fortunately didn't start smoking and my drinking stayed fairly moderate, so we'll count those as wins.

As I move out of the craziness of clerkship and onto the regular craziness of what will hopefully be the rest of my life, I'm trying to get some of those healthy habits back. I got a FitBit recently as a present and it's proved to be pretty good motivation (even though research shows it might be detrimental, at least to weight loss). I'm trying to push my daily steps a bit higher and I've started running again. On the sleep front, I'm now more aware of what helps me sleep soundly and what doesn't, thanks for FitBit's helpful - albeit somewhat unreliable - sleep tracker. It's also making me chart what I eat, which if nothing else is making me a bit more mindful of what goes in my stomach. It's led to some specific changes - since I was a kid, I'd have a glass of juice in the morning with breakfast. Every morning. While it gets presented as a healthy serving of fruit, juice is pretty much pure sugar with very little nutrition. I'm drinking tea now instead - never was a coffee drinker - and appreciating the change. Cutting it out eliminates a fair number of empty calories and tons of sugar from my diet.

I never want to be that hypocritical doctor lecturing my patients about good health when I'm not willing to make those changes myself. If only to understand the difficulty that can go along with making these positive lifestyle changes, I'm finding these new efforts worthwhile - and hopefully my own health improves as a result!

Communication Skills

When it comes to being a clerk, I consider myself pretty average. I keep up with my readings, know my patients pretty well, and generally put in a good effort into my clinical duties. However, I'm far from exceptional in any of these domains. Where I do consider myself a bit stronger is when it comes to communicating with patients and their families. I have plenty to learn and perfect on that front, but I'll put myself a bit ahead of the pack on that front.

I though I'd take a post to go through some of the basics of my approach to patient communication, as it's not something I feel is well taught or reinforced in medical education. I often see clerks, residents and staff committing some very basic errors when speaking with patients.

1) Establish rapport first, don't forget to maintain it

That having a good rapport with patients is critical to achieving optimal care with patients is no surprise to most medical students. It's an art - no two people will have the same method for achieving a good rapport yet drastically different approaches can be equally effective depending on the circumstance and the physician's personality. However, there are some basics to establishing and maintaining rapport which I've seen get forgotten, neglected, or perhaps never learned.

To start, taking 10-15 seconds at the beginning of an interaction for some simple pleasantries can go a long way. It's fine to get down to business quickly, but don't forget that your trust hasn't been earned just because you're a physician, and that first minute or two can make a world of difference. I try to work in a quick joke within that time if an appropriate opportunity arises - I find it puts people at ease far more easily than anything else. Most physicians understand this critical introductory period and do make an effort to come across as an actual human being for the first few minutes, though some are more effective than others, some use blatantly scripted approaches, and some forgo this entirely.

Where I see more stumbles is that once that initial phase passes, the physician's attempt to connect with patients disappears entirely. Once those pleasantries are completed, it's on to business, no time for things like emotions or empathy! This kills a lot of physician-patient relationships. Trust not only has to be earned, it has to be maintained. A few empathetic statements, jokes, or check-backs with the patient to establish understanding throughout the interaction are practically essential. They show that the patient is heard and that their presence is appreciated rather than simply tolerated.

2) Manage expectations

People will accept almost anything if they can prepare themselves for it. I've seen patients take news of a death sentence in stride because they knew it was coming before any words were spoken. The opposite is also true. People react very badly to surprises, even rather benign ones. Sick patients and their families, who may be emotionally and physically exhausted, are that much more prone to dealing with the unexpected poorly.

Medicine is inherently unpredictable. Doctors make educated guesses and can be pretty good at it, but very little is known with certainty. Good communication requires imparting some of that uncertainty to patients and their families. It's also vital to communicate exactly where that uncertainty lies. Are you uncertain because you don't know, or because you can't know? If you don't know, is it because you need input from a colleague, results from a test, or simply the time to let things play out?

Ultimately, the goal is to have their expectations be your expectations. You want your patients to hope for the best but plan for the worst, just as you will in your practice.

Being proactive is the key. Physicians frequently assume their patients are on the same page as them without confirming that this is the case. Taking 30 seconds to explain the plan, with considerations for how the plan might change and why, is an extremely important yet often neglected point of any patient interaction.

3) You're not all-powerful - don't pretend to be

Similar to the previous, be very clear about what is in your power and what isn't. Patients think doctors have a lot more authority and ability than we actually do. Physicians, sadly, tend to play into this myth. Fortunately, it's an easy trap to avoid.

Being clear about your role from the beginning is important, particularly for trainees. Never assume a patient knows what you can and can't do.

A major component of this is learning how to say "no" without it seeming like an exercise in power. The phrase I hear some doctors rely on which irks me so much because of the problems it causes patients (and other providers) is "I won't". A patient makes a request and the physician says "I won't do that". There is typically a good reason for the refusal and the physician either can't or shouldn't fulfill the request in the first place. Even with an explanation of the refusal, "I won't" sticks in patients minds, because they see the physician as being capable of helping, but actively choosing not to. It hurts a lot of patient-physician relationships. I like using "I can't" as much as possible, provided it's appropriate. Fortunately, most "I won't"s can be framed as "I can't"s. Patients are still disappointed by refusals presented this way, but I find they're less disappointed in me as a care provider, and that helps to maintain the therapeutic relationship a bit better. Physicians and patients have a natural imbalance, which patients certainly feel. By emphasizing your own lack of ability to change things with phrases like "I can't", it can help to lessen the feeling of that imbalance, and to make it clear that even if you aren't able to solve all their problems, you're still trying to do what you can.

4) Ensure you're on the same page

Even when a physician is an amazing communicator, patients don't always understand the full plan. Medicine is vast and confusing, even to the initiated. Human memory is flawed in healthy people and gets worse when we're sick or stressed. Letting patients know what's coming is only effective if they absorb what was said and remember it.

Some easy strategies can help retention. I frequently try to repeat whatever plan we agree on in a concise way at the end of an interview. I then provide an opportunity for questions, in case there are any points of confusion.

Even that leaves plenty of room for things to slip through the cracks. Two approaches I'd like to use more often - but have difficulty implementing as a learner - is having patients repeat back the plan and/or writing down the plan. At this stage, all my plans are tentative, subject to approval by my supervisors and, in many cases, subject to change without my knowledge. I can't pin down anything I say at the risk of having the patient remember my suggestions ahead of the attending physician's actual recommendations. I've already had at least one instance where this has caused trouble. So, for now, I've held off these strategies, but would like to implement them once I gain some more ability and independence.

None of the above elements are overly difficult to implement and with practice become second nature. However, they are not always intuitive, rarely taught, and virtually never reinforced in medical training. We could be doing a lot better to develop a culture of effective physician-patient communication.

Overconfidence

So, I got cocky. Had a run of incredibly good days on elective. I was nailing my evaluations, getting good diagnoses, and even developing reasonably complete plans for my patients. A few days felt like I could actually run the show in the near future. I still had plenty to learn, but I was spending more of my time refining my approach and decision-making than starting from the basics. I was even trying to work on speed in my assessments.

Well, that came crashing to a halt this past week. I had two days where it seemed like I couldn't get anything right. My evaluations were incomplete, my diagnoses were flawed and my plans were lacking. I was horribly slow, even for my stage of training. I wasn't close to being independent - heck, I was barely adequate for a 4th year medical student.

It's been a big wake-up call. On reflection, I stopped doing the things that got me to this point successfully. I wasn't keep up with my readings. I wasn't thinking through my approach when I stepped in the room, acting more on instinct than deliberately considering the possibilities. I rushed through my presentations, leading to slower reviews with my supervisors and costing more time overall.

So, I'm trying to do more regular reading, every night if I can, on 1-2 topics. I attempted to be more deliberative in my assessments and more organized in my presentations. Most importantly, I've tried not to be so hard on myself. I won't get every evaluation perfect at this stage, not even close. I needed to recognize that while I have made large strides in my abilities, I'm still in the learning phase of my training. I'm going to get things wrong, miss things I should pick up on, and that's ok for now.

Good reminder that it's alright to have a bad day or two - as long as you learn from them.

Electives - Initial Thoughts

Got to start my electives over the past few weeks. They say the 4th year of medicine is the best year, and based on my experiences so far, it's hard to disagree. I don't have to worry about evaluations, I'm getting sleep and a bit of actual exercise, and I'm learning a ton. Getting to choose my rotations, or at least have significant input on them, is a major bonus. Learning comes so much easier when you want to learn and are motivated to do so.

It is a bit disorienting though. Perhaps not quite as much as clerkship, because I at least know the medicine well enough. Yet, being in a different environment every 2 weeks, particularly when that often involves being in a different city, it does take a fair bit of mental energy just to keep up.

There's a trade-off between variety and consistency when it comes to absorbing new information. Too much variety and there's so much rattling around in your brain that little if anything sticks. Too much consistency and you only pick up what's right in front of you, missing experiences you may have to encounter on your own later down the line. Right now I'm on the "variety" side of things and I am definitely missing my time where I could count on doing roughly the same thing for weeks on end - I'm getting a lot of experience I otherwise wouldn't, but less is sticking than I'd like.

The other wrinkle here is that this is my main chance to explore different settings for residency considerations. As someone leaning heavily into FM, the main question I'm wrestling with right now is how rural do I want to go? I knew I didn't want to do the extremes on either end - I don't want to be in the GTA, nor do I want to do overly remote medicine. However, that still leaves open anything from mid-sized cities to small towns with only a few thousand inhabitants. I don't have any major preferences when it comes to living in these locations, so it's coming down to practice types. In larger centres, FM is much more restricted to clinic work, home visits, and nursing home care, possibly with some OB thrown in. Smaller centres, you could be running clinic, covering the ER, taking care of inpatients, then doing trips to people's houses or to nursing homes, potentially all in the same day.

I'll have more to say on that soon - right now, I'm trying to keep an open mind to fully explore each of these settings and which ones might be a better fit for my residency, and my eventual practice.

How Could We Reform Physician Compensation?

With the rejection of the tPSA by OMA members, we're back to square one in the negotiation with the Ontario government regarding physician compensation. It will likely be a long, ugly battle, just as it was before the tPSA came to light. Still, it's a good opportunity to delve into the discussion about what a reasonable adjustment to physician compensation could look like. After all, while I was strongly opposed to the tPSA, I'm not at all opposed to sensible efforts to save money on physician compensation, and I believe there are ways to do it which are in the best interests of patients and taxpayers which wouldn't unduly burden physicians themselves.

1) Implement Relativity

This came up frequently in the "Yes" side of the tPSA arguments and, despite being a "No" voter, I support this approach. Relativity in the context of physician payment negotiations in Ontario essentially means that physicians should be paid comparable amounts for the work that they do. More specifically, the argument is that if cuts are to occur, they should fall on those who are paid more than their counterparts with similar training and working conditions.

There are some specialties where physicians clearly earn more than is justified, in relative terms at least. I could name several specialties or subspecialties here, but I'll single out Ophthalmology, as it's one of the more commonly cited examples. Ophthalmologists have extremely high gross billings on average. Their high overhead reduces this number considerably, but their take-home income is still quite high. Their patients are generally low acuity with threats to morbidity rather than mortality, and their working hours are on the lower end, particularly for a surgical specialty. Importantly, there is no shortage of individuals wanting to work in Ophthalmology in Ontario - both job openings and residency positions are extremely competitive - so we could cut Ophthalmology compensation without significantly affecting our ability to fill available positions. Ophthalmology does involve complex, technical work with an important impact on quality of life for their patients and their pay should reflect that expertise. However, with outsized incomes, the overall Ophthalmology compensation could be cut without significant ill-effects on patient care, as could the income for a number of other specialties or subspecialties.

One point to mention here - in no way would I argue for equal pay for all practitioners, or even equal hourly pay. I'm going into Family Medicine (if I have any say) and expect to earn on the lower end of things for a physician. That's fair to me - I'm actively choosing to avoid long training times and long work hours with high acuity patients (outside of some ER shifts potentially). Some inequality in pay is justified.

2) Eliminate Cash Cows

Overpay between specialties is worth addressing, but so is overpay within specialties. Each specialty tends to have its own cash cows, procedures or practice arrangements that overpay relative to other activities. These cash cows skew practice patterns. The economics of healthcare do not work the same way they do for other products, but many of the same principles apply. In this case, if you pay doctors more for doing something, they'll do that something more often, even if that something isn't the best use of time or resources. It also produces some inequality within specialties, as practitioners who establish themselves with a certain high-pay procedure, or control the infrastructure necessary to perform it, end up with higher incomes than those without the privilege. Eliminating cash cows by pricing high-pay activities more modestly could provide some savings with a neutral or possibly even beneficial effect on patient health.

There are a few caveats here, however. In some cases, cash cows are actually a case of good incentives. Some activities are inherently undesirable for practitioners, yet necessary for patients. High compensation in these situations may be required to provide patient access. Another consideration is that cash cows can compensate for low-paying or even net negative activities. Our billing system is bad enough that some activities actually cost practitioners money, or pay so little that they aren't economically feasible on their own. Physicians often still provide these procedures or services because they're valuable for their patients, while making up for the lost time and money through higher-yield services. Taking away those overpaid activities means fewer practitioners can realistically afford to provide underpaid activities.

Bottom line is that adjustments to billing codes have a significant potential to save money on healthcare costs, but require careful consideration. There are a lot of secondary effects to changing billing codes that aren't immediately apparent to an outsider.

3) Strengthen Primary Care

Reducing physician costs in the provincial budget really can only be done one of two ways - reduce the cost per service provided by physicians, or reduce the number of services provided. The first two items discussed deal with the former. The rest of this piece will focus on the latter.

Primary care is the gateway to healthcare services, whether through Family Physicians or through Emergency Rooms. We rely on these practitioners to restrict access to specialists only to those who truly need them. The more that primary care providers can manage without calling on specialists, the less specialty services will be used. By strengthening the capabilities of Family Physicians, we might be able to save money on more expensive specialists, reducing how often patients require their care.

This is obviously easier said than done and in many cases, not a good idea. Primary care physicians don't see some conditions often enough to develop sufficient expertise and they shouldn't hesitate to get experts involved in these situations. Likewise, other expensive elements to healthcare, such as some diagnostics or interventions, are restricted to specialists to release, limiting their use and arguably saving the overall system a fair bit of money. Opening these resources up to Family Physicians would not be beneficial to patients or taxpayers.

Nevertheless, with reasonably wide variation in referral practices between Family Physicians, especially between locations, we do have room to cut back on referrals without sacrificing quality of care or adding costs to other parts of medicine. Emphasizing (and ideally compensating) continuing medical education, while strengthening the training for primary care providers (particularly in medical school!) would be my favoured initial methods. Incentive schemes to keep referrals to a minimum may be worth considering, if they can be carefully constructed not to punish necessary referrals.

4) Train Fewer Doctors

Ok, this is a can of worms, but let's open it just a little bit. Canada tried this approach and it largely didn't work. Back in the 90's, Canada's medical schools didn't keep up with population growth and in some cases, medical school enrollment was actively curtailed. Of course, physician services were still necessary, and ultimately, healthcare costs continued to rise unimpeded. Physicians, now scarce, saw their salaries rise, while non-physician providers like Nurse Practitioners and Physician Assistants slowly grew in number. Eventually, the deficit in physicians was too high and Canada reversed course, massively expanding medical school enrollment while opening up new residency opportunities for foreign-trained physicians. The idea that restricting physician numbers could save money was fairly clearly wrong.

Well, sort of. The problem in the 90's was that Canada restricted physician numbers so much that baseline demand for services couldn't be met. That led to compensatory spending to make up that deficit. Now, however, physician numbers are much closer to the OCED average and still on the rise. We're starting to see some first signs of physician oversupply, with unemployment and underemployment on the rise, but this has been largely concentrated in resource intensive, hospital-based specialties where jobs can be restricted by constraining the availability of those supporting resources. This speaks to an inherent problem in funding physicians to meet patient demand - demand for healthcare services often expand with supply and physicians can create their own demand. Specialties that can finance their own infrastructure tend to have great job markets regardless of the local supply of physicians.

The example I always mention is Psychiatrists in Toronto. They are in far greater supply there than in smaller cities and rural areas, yet do not seem to have trouble getting work and make salaries comparable with national averages. They just take care of far fewer patients than their counterparts elsewhere, seeing them more often or for longer. This isn't necessarily a bad thing, but it clearly a more expensive arrangement for the province. This is hardly a unique situation. Most specialties, including Family Practitioners, could easily double (or more) the number of people in their clinics or procedure rooms if they had the time and resources to do so. As we start to see the number of physicians rise, and especially as we see more students going into fields like Family Medicine, Psychiatry, and Geriatrics, we could see physician billings substantially increase, as these new practitioners will not be nearly as constrained by public resources, and can cause - rather than simply respond to - increasing demand for healthcare. I do think we need to shift more physicians towards these specialties, which are likely still undersupplied relative to other specialties, but we are likely overshooting on overall physician supply. Cutting back on this oversupply would likely help the bottom line in the long run.