Social Commentary

With my Internal block wrapping up and no exams or evaluations on the immediate horizon, I've had a chance to do some more reading than normal. Since, like most people my age, I'm addicted to the internet, this has mostly consisted of reading internet articles. A few are worth mentioning and deserve a response.

1) I'm a freelance writer. I refuse to work for free by Yasmin Nair - via Vox.com

I'm a huge fan of Vox's "First Person" series, which has done a great job of bringing compelling or non-mainstream viewpoints to print. Part of the reason I'm a fan is that it lets me read a number of well-written pieces that I completely disagree with. This is one of them.

The central argument here is that the massive growth in people writing for free is causing writing to be viewed more like a hobby, leaving professional writers like her out in the cold while simultaneous degrading the quality of popularly-read writing. In particular, the author believes that this shift toward unpaid writers is perpetuating societal inequality, in a number of ways, whether it's editors profiting off unpaid work, or poorer individuals squeezed out of the writing marketplace by richer writers who earn money in other vocations and write on their free time.

On one hand, I acknowledge that the old model of writing is dying. It's undoubtedly hard to earn a living doing nothing but writing, especially when you exclude journalism as well as creative works like novels or poetry. Where I disagree is that I'm not sure that's a bad thing and I'm very skeptical that, on the whole, this contributes to inequality.

I write for free. It is a hobby for me. I'm not going to stop doing something I enjoy because someone else would like to be paid for doing something similar. The thing is, there are authors who do make a living off their writing. These are usually fairly exceptional authors in one way or another, either because they produce a very high quality of writing, have particularly unique or compelling insights, or appeal to a specific group of individuals. They deserve to be paid for their services. However, most writers are not exceptional and, as such, there's not much of a monetary demand for their work. I don't see much problem with that - if an author isn't offering value beyond what others are more than willing to provide for free, there's no justification for paying them.

The analogy I draw is sports. I like playing basketball. I'm not very good. Certainly no one would pay to watch me play. NBA players do get paid because they're amazing and fun to watch. Rec-league players like me don't, and a fellow rec-league player has no right to get upset because they aren't earning a salary for playing the game.

Where there is cause for concern is where a person's writing is earning money, just not for them. In the sports analogy, that would be college basketball. In the Vox piece, that is places like the Huffington Post. That's a fair criticism - executives shouldn't be raking in the cash at the expense of those actually doing the work - but there are shades of grey in there. Editing, producing, publishing, and advertising is hard, grueling work. It's not hard to get people to write without compensation (it's fun), but very hard to get people to maintain a publication for free (it's less fun). For example, she faults OpenDemocracy for having a paid staff, but their salaries are hardly extravagant and reducing those salaries would provide almost no funds for their writers.

As for inequality, I'm sympathetic to the notion that free writing shifts the balance of publications towards wealthier individuals who can afford to write for free. However, I think that narrow view misses the broader gains for inequality from increasingly free writing. For one, low writing costs means low consumer costs. Anyone can read what I write! It's free! Whereas in the past writing may have been prohibitively expensive to consume for those with lower socioeconomic status, anyone with access to a computer can now read a huge amount of information from a wide variety of authors. I have trouble reconciling the benefit of paying authors more with the downsides of charging consumers more. Writing shouldn't be only the purview of the rich, but good ideas shouldn't only for the eyes of the wealthy either.

2) Don’t Give Up! by Gregory Shumer - via NEJM Journal Watch

This article concerns a now-senior resident reflecting on the difficulties they had when starting medical school and how they persevered through those difficulties to get to where they are. Medical school - and life in general - have challenges and rising to those challenges is laudable. While not a controversial viewpoint, it is good to read a reminder that hard work and dedication can make trials in life manageable.

So why am I mentioning this article at all, if it's point is relatively simple and one I agree with? Because the author put their struggles in the context of systemic burnout among physicians. More importantly, he proposed solutions to burnout including "try to keep those feelings at bay" and "a greater commitment to [your] long-term goals". There's an attitude in parts of medicine that ascribes burnout to personal failings on the part of trainees or physicians. Going along with that, any solutions to burnout are targeted at individuals, presumably trying to correct or prevent those failings. Even the author's relatively helpful suggestions, "some personal time, a change of direction, or a conversation with someone you trust and admire as a mentor", all buy into this notion of burnout as fundamentally the responsibility of individual physicians.

However, burnout isn't a personal failing, it's a systemic problem. I have no qualms about revealing that halfway through clerkship, 6 months into it now, I've had symptoms of burnout for at least half that time, no less than 3 months in total. I really haven't been struggling in my duties during clerkship, and in some ways I've been excelling, yet I'm still burnt out more often than not. Trying harder isn't going to change the fact that I'm sleep-deprived, or give me more time with my loved ones, fix the many broken parts I see in medicine, or make medical education more effective - I'm already doing all I can to manage the elements to being a medical student that are causing me to be burnt out, but most of them are completely beyond my control.

I'm glad that the author was able to redouble their efforts and push through their initial challenges when starting medicine. However, that's not going to help the vast majority of people dealing with burnout and I find it incredibly misguided, if not outright dangerous, to continue to put the responsibility of dealing with physician or trainee burnout primarily on the shoulders of those experiencing it. They're already doing what they can to avoid it - no one wants to be burnt out! Burnout is a systemic problem, and it will only be solved with systemic change.

Re-emphasizing the Manager Role

I recently shared my thoughts on Internal Medicine and my time on CTU (long story short - not a fan). The experience got me thinking about an older post of mine on CanMEDS roles and how the Manager role is an often-neglected yet vitally important aspect to being a physician.

Clerkship has dramatically changed some of my views on medicine, but this is one that couldn't have been reinforced more. The CTU is very much a team and the attending physician - as much as us clerks and the residents rely on them for their substantial medical knowledge - their main responsibility is to manage a rather large team of learners. I found I had the best experience - and patients seemed to have the best outcomes - not when the best medical expert was in charge of the CTU, but when the best manager was in charge.

The thing is, in medicine there aren't many people who aren't exceptionally knowledgeable. I like to think I'm a fairly intelligent, hard-working person, but truth be told I'm a pretty average medical student. I'm perfectly fine with that though and haven't focused my efforts on improving my standing relative to my class. The reason for this is that when I think of the physicians who have done the most capable job, in terms of what colleagues and patients think of them as well as what I've seen of their ability to do provide meaningful help for their patients, they're rarely the walking textbooks other physicians seem to be. Rather they incorporate all those other CanMEDS competencies, including the manager role, along with a high level of knowledge that is near-universal in medicine.

So, as long as my knowledge base can be reasonably described as average or better relative to my peers, I try to focus on other things, like being a good manager, or a good communicator, or a good advocate. In the long run, I believe that's what will make me the best physician I can be for my patients.

Likes and Dislikes in Internal Medicine

Continuing on with my "Likes and Dislikes" series on the rotations I've done, next up is Internal Medicine. It's a huge block at my school, including over a month on our Clinical Teaching Unit (which is basically general medicine). Plenty of time to get a good feel for the specialty, so this'll be a long post. Here are my thoughts:

1) I really don't like inpatient medicine

I've said it before and I'll repeat myself here. Inpatient medicine, at least at the academic hospitals I've worked at so far, depresses me. The people I've worked with are generally quite nice, supportive, and capable, while the medicine is deep and interesting, but there are so many system-level problems that it makes the whole thing unbearable for me. Patients, doctors, learners and other healthcare workers all seem to get a pretty raw deal. Some of these system-level issues will get addressed or even solved in the coming years, but a lot of them won't. Large academic centres are huge beasts with so many competing priorities and parties with different objectives that solutions come slowly or with unwelcome side-effects. Hard for me to see me spending my life dealing with those challenges.

2) I really, really don't like inpatient consult medicine.

If there's one part of inpatient medicine that exemplifies my dislike for it, it's in the use of consulting services. Consulting services are basically experts in a particular field who are brought in to help with particularly challenging patients with established or potential diagnoses in that expert's area of study. That sounds great in theory and it works reasonably well in outpatient medicine, but for inpatients it's crippled by one major issue - the consults are caring for the patient at the same time and communication between all parties involved is horrible. It's like cooking a meal with 4 chefs all trying to make a good meal, but all attempting to make a different meal and only occasionally telling the other chefs their plans, ideas, or intentions. Not a good system.

For the record, patients see this terrible communication system and they don't like it at all. However, as I did before I started this rotation, they blame individual physicians. That's not entirely false, some physicians are terrible communicators too, but the more fundamental problem is our system is not set up for effective or efficient transmission of information. Even the most well-intentioned, capable physicians will not coordinate care nearly as well as is necessary, it's just not routinely feasible with the processes currently in place.

3) Lots of independence - and lots of learning

Internal is amazing for reinforcing the basics of medicine. A reasonably high emphasis on teaching is a big part of that, but the main element is independence. When you're responsible for your own work - and you get quite a bit of it - you have to learn to survive. Plus, since it's all contextual knowledge, it sticks in your brain pretty well. It's like studying without the pain of studying!

4) Lots of independence - maybe too much

The downside of independence is that it can be given too quickly, putting students and other learners in a position where they have more responsibility than they can handle, or have to complete tasks beyond their training or experience. This has happened... frequently. It's awkward for trainees, difficult to address for instructors (who generally have to put the trainees in that situation or go to extremes to avoid it), and potentially hazardous for patients. Yet, it's how much of medical education seems to operate - sink or swim, even if it means dragging patients down with you.

5) Be Nice to the Nurses
When someone comes into hospital, they're not there for the doctors, they're there for the nurses. Doctors can't do that much more in hospital for patients than they can out of hospital, but nurses are essential to maintaining health while the reason for coming into hospital is investigated and managed. The further along I got in the rotation, the more I learned to lean on nurses for their perspective and expertise. I've got more than a few than a few stories of suggesting a treatment plan that came directly from a nurses' mouth that had a positive impact on patient care (I always tried to give the nurses credit, though that positive feedback never gets back to them as often as it should).

6) The Happiness Test
I hate to say it, but at least when it comes to people on the clinical teaching unit, the answer is no. They put on a brave face, but most are more than willing to admit that they do not like their time on the CTU. It actually causes a bit of a vicious cycle, where residents try to take vacation during their CTU blocks to spend less time there, thereby increasing how much work there is for everyone else to do and making CTU that much less enjoyable. While interest in General Internal Medicine has grown, most people in Internal seem to merely tolerate general medicine itself until they can sub-specialize into what they actually want to do. The result is a number of not-so-happy people on rotation. Considering my own level of happiness on the rotation, I don't blame them.

Work Hours and Handovers

A major argument against restriction of work hours for residents (or staff, though that gets less attention) is the notion of increased handovers. The basic story goes that when you have residents work fewer hours, or at least fewer hours in a row, they have to handover the care of their patients to other residents more often and since handovers are well-established as leading to error, more handovers mean more errors. It is thus hypothesized that any gains made on resident fatigue by restricting hours will be eliminated by increased problems associated with handovers.

When work hour restrictions were put in place in the US, studies on healthcare quality came back pretty equivocal, so the hypothesis appeared valid and has been seized upon by many with an interest in medical education, particularly those opposed to work hour restrictions. I accepted this theory as well, since it seemed to fit the evidence and was plausible in theory.

Now, acceptance of this theory didn't change my views on reducing work hours in medicine, since handovers are not an inherent problem, but rather one that could be addressed and improved. Moreover, since our current system necessarily involves a lot of handovers, fixing them should be a top priority anyway. As a result, any losses in care due to increased handovers associated with shorter working hours should, if anything, get better as time goes on, allowing any gains from those shorter hours to be realized.

However, the more I look at the problem, the less I'm convinced this theory holds much water in the first place, at least not in many cases.

For example, shorter shifts don't necessarily lead to more handovers for the majority of patients. Individuals on call for 24 hour shifts don't typically just take care of their own patients, they take care of patients on their "team", many of which are cared for by other team members. When I'm on call during my current rotation, I am responsible for up to 30 patients, yet most days I only care for 4-6 patients. Residents often take on a bit more work, but even then, they're unlikely to be familiar with more than 10 patients. They need to be updated - or receive handover - from the other members of the team. If we had two distinct shifts taking care of a set of patients, one day shift and one night shift, the total number of handovers would be virtually unchanged for the majority of patients.

Likewise, not all handovers are created equal - handing over a patient that both parties are reasonably familiar with is a much different situation than handing over a patient that the receiving party has never cared for before. This gets back to a more fluid concept of continuity of care which I've written about before, where continuity of care doesn't mean one physician caring for one patient, but rather one physician maintaining the same role in caring for that one patient.

So how do I explain the rather equivocal results from studies on resident work hour restrictions? My current belief is that work hour restrictions failed to achieve their process goal, which was improving resident fatigue. Through a combination of increased work intensity, scheduling loopholes, and well, simply ignoring the restrictions, residency programs simply found creative ways to continue to work their residents far, far too hard. We didn't see a change in patient outcomes, because we never really saw a change in resident working conditions, simply trading one inadequate resident work system for another.

I can't dismiss handovers as a factor entirely, since I've seen first-hand how poor handovers can cause substantial problems for patients. Yet, when it comes to work hour restrictions, I'm coming around to the conclusion that they're used a bit as a red herring, part of a rhetoric thrown out to justify maintaining the status quo on work hours, without much conclusive evidence to demonstrate that the status quo should be maintained.

Nothing Special

Medical culture is full of falsehoods, things which are believed or assumed to be true which aren't, or at least aren't true all of the time. The further I get in, the more assumed truths I find out to be misleading or outright wrong, but there's one always seems to stick around, which I'm reminded of virtually every day.

This falsehood is that physicians are special.

It's the big lie of medicine. We promote it. Schools promote it. Hospitals promote it. Even patients promote it. And yet, it's not true.

Ok, sure, the average physician is usually pretty smart and has worked pretty hard to get to where they are. But that's about it.

With a few exceptions, physicians aren't geniuses. We aren't uniquely capable workhorses. We can't withstand sleepless nights any better than the average person, we can't memorize facts better than the next person, we don't have unique insight into the human condition, or an increased ability to handle stressful situations.

Doctors are just people. Regular, ordinary, slightly neurotic people.

When we forget that, we make very poor decisions. We overestimate our ability to diagnose and treat patients, often while ignoring contradictory information. We push ourselves and our bodies farther than they can handle, then deny that we've gone too far. We study for hours, believing it will all sink in, yet forget much of what we read because human memory simply doesn't work that way.

System-level decisions also draw on the myth of the super-human doctor, to disastrous effect. 24 hour shifts (down from 36 hour shifts). 80 hour work weeks (down from 100 hour work weeks). Drinking-from-a-firehose style learning. Chronic understaffing and/or overloading of patient volumes. Obviously there are other factors at play here - money being a big one - but I find a lot of systemic problems in medicine are supported by the notion that physicians can do more than an average human being and it's perpetuated because a lot of physicians believe it themselves.

At some point, the profession has to take a step back and admit there's nothing special about us - and that we shouldn't be given special (or worse) treatment as a result.

Job Market and Physician Career Choices

As I've said, one of the parts of clerkship I really enjoy is getting more opportunity to hear from residents and other clerks about what their future career goals are and how they're going about achieving them. Rather than just hearing from your friends, you suddenly get exposure to a lot of diverse opinions and priorities. As someone overly interested in the medical training pipeline, that broad on-the-ground perspective is invaluable.

It could be just the group I'm talking to, but the trend in long-term career interests definitely seems to be responding to the job market, with one big exception. That exception is those interested in surgery, who seem perpetually immune to job market changes, though I'll admit there seems to be a trend away from the truly awful job markets like Ortho and Neurosurg. For the non-surgeons, fields with good job markets certainly seem to be getting more attention: Family, Psych, Emerg, Derm. Likewise, talking to Internal Medicine residents, the in-demand subspecialties are getting more attention, particularly Geriatrics.

However, while trainees seem increasingly responsive to job market considerations, the supply of physicians isn't. For a variety of reasons, the number of trainees each year in each specialty is roughly constant. There's some slow movement based on job markets, but that's decided by governments, medical schools and residency programs, not by trainee interest. Specialties get more or less competitive in the sense that an interested applicant may have a higher or lower chance of securing a highly-desired spot, but in the end the vast majority of Canadian grads get matched somewhere and the vast majority of offered residency positions get filled, whether by Canadian grads or international students. There are market forces at work, but the physician training pipeline isn't a market system (whether it should is a whole other discussion), so it's not responding to those forces, or is doing so at glacier speed.

I'm eager to see what this year's match results show. In particular, I've got my eye on Psych and Emerg. Psych's traditionally been an easy specialty to match into, but mental health is seen as increasingly important and it's hard to beat its combination of job market and lifestyle. On the other end, Emerg has been ultra-competitive, looks to be even more competitive, yet still has one of the better job markets. How those fields change in terms of competitiveness - and how schools respond to that change - will tell us a lot about how physician human resources are going to look in the next couple decades.

Continuity of Care

Continuity of care, as ideally envisioned, involves a patient being cared for by a single provider each and every time they interact with the healthcare system, or at least every time they come for care for a specific condition.

That situation is, of course, impossible. No medical professional has enough knowledge and skills to care for a person once their medical condition becomes the least bit complicated. There's a reason we have a progressive increase in specialization and sub-specialization, one person just can't know enough. More importantly, one person can't be there 24/7. Anything that requires urgent or continual attention means bringing someone new into the care of the patient.

Despite being relatively well-accepted that we can't have a single person care for a patient, and that continuity of care has to involve more than one provider, efforts to improve continuity of care are still largely centered around minimizing the number of providers. That's not enough.

For one, it means we are still terrible at maintaining good continuity of care between providers. Handovers, whether in person or by written communication, are fraught with errors and omissions. As a medical student, I do a fair number of dictations that serve as the definitive record of a patient's stay in hospital or visit to a clinic. I have received zero formal training on how to do this appropriately or efficiently. Not yet being a true medical expert, I don't always appreciate what details are pertinent and which ones aren't, which means I alternative miss important information, or include unimportant minutiae. More than a few times, I've had to dictate discharge summaries for patients I've never met, or only met once briefly. All my dictations have to be signed off by my supervising physician, but they're busy and are often relying on me or other trainees to know the details of the patient's visit, so these reports often get submitted with no or minimal changes.

Even how we try to maintain a single provider in the care of a patient could use a good dose of extra scrutiny. Call schedules for residents are a major problem in my mind. In inpatient medicine in academic centers, teams are often comprised on a single consultant physician and multiple learners. Each learner takes a set of patients to manage during the day. To cover nights, individuals from the team take turns on 24 hour shifts. That sounds like good continuity of care, but for two giant holes. First, the learner on the team doesn't know all the patients on their team, at least not well. They cover a subset during the day, so everyone else is a stranger. Not good. Secondly, since the learner gets a post-call day, the patients they typically cover during the day have to be covered by other learners who likely haven't met their patients before.

Some programs are playing around with night float - where a person repeatedly cover a team overnight for multiple nights - which I think makes a lot more sense. The care needed at night and the care needed during the day are often very different. Having continuity from one night to the next, as well as one day to the next, is generally more valuable than continuity from day to night. However, few programs have tried this out yet, and the approach of those who have isn't always that great for the health of those on the night shifts - some have tried 16 hours on, 8 hours off, which is a recipe for inadequate sleep and through-the-roof stress. There are ways to ameliorate this (might write more on that later), but it shows where the debate currently stands when it comes to actual practice. The medical community does talk a lot about improving continuity of care, but when it comes to practical solutions, we're barely putting our toe in the water.

Normal Saline

There are no magic pills in medicine, but if there's one thing that comes close, it's IV normal saline. I'm still amazed at how many people improve by just getting a little bit of extra fluids in their veins. Lives are saved by normal saline. Otherwise intractable medical conditions are effectively treated with IV normal saline.

There are limits, of course - it's just salt water, it can't cure cancer, reverse dementia, or treat depression. Still, I've seen a couple people improve dramatically over the last few weeks when given nothing but a bit of extra fluid. It's a helpful reminder that good medicine doesn't always require technical or sophisticated interventions. Heck, most good medicine doesn't require technical or sophisticated interventions. Sometimes salt water works just fine.

Study Time

I'm most of the way through my Internal block now and it means it's time for exams again! (Hooray...)

The challenge with Internal Medicine is that it's such a voluminous field. It covers almost everything, without a specific emphasis on anything. That makes it very difficult to know what to study, or how much to study. I've been doing fine with my clinical duties, but there does seem to be a lot of studying needed on top of the clinical experience.

Anyway, putting my nose to the grindstone for the weekend, in the hopes that my meager efforts are enough to keep my head above water for the coming test!