CaRMS Stats 2016!

CaRMS released their stats from the 2016 match today. I get way too excited about the chance to analyze these numbers. That's especially true this time around since this the last year before I'm part of those numbers.

Anyway, here are the match rates to each specialty for those who ranked that specialty first, in order of competitiveness. The CFMS always puts out the stats below as well, but they take a few months to get them up and I get impatient.

Specialty		% Matched 1st Choice Discipline	% Alternative Discipline
Dermatology		43.8%	43.8%
Plastic Surgery		46.0%	22.0%
Emergency Medicine		50.4%	41.1%
Physical Medicine & Rehabilitation		60.0%	20.0%
Medical Microbiology		63.6%	18.2%
Urology		64.3%	28.6%
Neurosurgery		66.7%	12.5%
Nuclear Medicine		66.7%	16.7%
Otolaryngology		69.0%	21.4%
Ophthalmology		69.1%	18.2%
Obstetrics & Gynecology		69.7%	22.0%
Anesthesiology		73.4%	17.3%
Pediatrics		74.9%	18.0%
Cardiac Surgery		75.0%	8.3%
General Pathology		75.0%	25.0%
Neurology - Pediatric		75.0%	25.0%
Vascular Surgery		75.0%	25.0%
Public Health & Preventive Medicine		77.8%	16.7%
General Surgery		78.6%	11.2%
Orthopedic Surgery		87.3%	7.3%
Diagnostic Radiology		88.2%	9.2%
Internal Medicine		88.2%	6.8%
Psychiatry		88.4%	8.7%
Neurology		90.5%	7.1%
Family Medicine		96.5%	1.4%
Anatomical Pathology		100.0%	0.0%
Hematological Pathology		100.0%	0.0%
Laboratory Medicine		100.0%	0.0%
Medical Genetics		100.0%	0.0%
Radiation Oncology		100.0%	0.0%

Ignoring the smaller specialties that tend to have a lot of year-to-year variance, the big things that jump out at me at the uniquely competitive years for PM&R, Urology and Internal Medicine. Diagnostic Radiology went right the other direction, with a rather uniquely uncompetitive match by their standards.

Derm, Plastics and Emerg continue their reign atop the competitiveness standings, which is no surprise, but they keep pushing that boundary further. Derm and Emerg are at least maintaining a decent back-up match rate. They both can fairly naturally back-up into Family Medicine, so that certainly helps. Plastics is another story... like most surgical specialties, it doesn't have a natural back-up option. All the other surgical specialties are decently competitive themselves and non-surgical specialties can stand out like a sore thumb in a Plastics-oriented application package.

As expected, Family Medicine remains the surest option - but not a guarantee - for those who simply want to match to something. Despite its increasing competitiveness, Internal is also the best non-FM option for a back-up specialty.

I'll likely post a bit more on this later - there's always a fair bit to parse out from the CaRMS numbers and this year is no exception. With the possible exception of some PM&R gunners, I don't think this year's stats should change anyone's approach for next year, but I'll try to go into more depth on that next time.

Beginning of the End (of Clerkship)

One more block left of Clerkship and I'm done. I can see the end of this year in sight, and then it's onto the awesomeness of 4th year electives. With the sun finally coming out as well, it's a fairly invigorating time!

Well, except for the one small detail that the final block standing between me and the finish line is surgery...

I am not a surgeon. My physical skills are fine, I can behave myself in an OR, but my tolerance for the personal and physical sacrifices necessary to make it as a surgeon is pretty low. I don't care how amazing performing surgeries is, I have no interest in doing anything for 12 hours a day every day. Heck, if you told me surgery was playing video games and eating ice cream 12 hours a day, I'd still probably have to say no. And I like video games and ice cream a whole lot more than I like being in an OR.

We had our orientation today for the surgery block and it went really well, but looming over it all was the prospect (promise?) of missing out on a lot of sleep, a lot of life, or both. I'm hoping it won't be as bad as I'm dreading it'll be and/or that my enthusiasm for being on the home stretch of clerkship will carry me through relatively unscathed. It'll all be done in 3 months, one way or another, so I suppose I should just strap in for the ride.

Gord Downie

I'd be remiss to not mention the awful news announcing that Gord Downie has terminal brain cancer.

The Tragically Hip are one of those few bands that has been producing solid music for decades while being unabashedly Canadian. I have their compilation album which is 37 songs and I can honestly say there's not one song there I dislike. And that was released in 2005! They've kept making pretty good music since then.

I'm a bit on the older side for Medical School, but not that far on the older side, so I didn't start getting into half-decent music until well after The Hip's better-known hits were already a distant memory. The first album of their's I picked up was World Container, where I got caught up by its title song:

Anyway... just reflecting today on how cancer sucks, Canadian music is pretty awesome, and how it's worth enjoying the good things in life while we still can. I'll leave you with one of my favourite Hip songs - it seems appropriate this week.

Likes and Dislikes in Family Medicine

Whew... I'm coming to the three-quarter mark of my clerkship rotation, just finishing up my Family Medicine rotation and staring down the barrel of my final rotation in Surgery. Time for another "Likes and Dislikes" post. Full disclosure - I've pretty much settled on applying to Family Medicine come CaRMS time, so this post may be a little bit biased...


1) Continuity of care is awesome
Getting to see the same patient multiple times in the same rotation is not only gratifying but great for learning. The rest of clerkship is incredibly fragmented - aside from inpatients who we see for as long as they're in hospital, clerks usually don't see a patient more than once. Here, I got to see the results of some of my diagnoses and treatment plan. It makes the experience a lot more memorable, makes care a heck of a lot easier, and makes learning that much more enjoyable.

2) Some people are a drain on healthcare resources
It should go without saying that same individuals consume more in healthcare funding than others. In family medicine, it was pretty easy to pick out the frequent visitors. If all a high-volume healthcare user does is come to their Family Physician too often, we're not in bad shape - FM visits don't cost much at all - but the spiral in costs from that point definitely adds up. Lab tests, imaging, consults...

In some cases these costs are justified and provider-driven. Someone at high risk of cardiac problems will get a lot of attention from their Family Physician and rightfully so. Some are... less beneficial. Anxiety takes a huge toll on the healthcare system in ways that have nothing to do with managing anxiety. Likewise, patients with significant social dysfunction inevitably find their way into interacting with the healthcare system for relatively non-productive reasons.

All this said, it's all too easy to blame the patients themselves for this overuse, particularly for a primary care provider dealing with the same person over and over again. These patients all have problems that deserve attention, it's just not necessarily the problem they're putting to the physician. Healthcare has its limits and in terms of improving health, it's only one part of the solution.

3) Why are regular hours a bad thing again?
I haven't worked a night for almost two months now. I have small but discrete periods of time in the morning and evening to either relax or work on side-projects. I'm getting exercise again, if only small amounts. Yet I feel like I'm learning about as much as I was during my more "intensive" rotations. This is undoubtedly where my preconceived notions come into play, but I'm still baffled why medical education is so set on the idea of long, intensive hours, particularly at this stage in the game. More experience is undoubtedly helpful, but fatigue is undoubtedly hurtful. It has been good to feel relatively rested again.

4) Rush, rush, rush
The main downside I see in Family Medicine is a strong incentive to rush patient visits. The economic constraints require seeing a lot of patients as quickly as possible in order to cover overhead. I had dreams of a practice where my patients were scheduled every 20-30 minutes and I could really take my time with my patients. Now, I don't believe that's feasible in most set-ups. Billing codes in Family Medicine are just too low to allow for deep, methodical visits like that on a regular basis.

However, they may not be necessary either. It's taking me about 30 minutes per patient right now, but that's considering I'm dealing with conditions I'm still learning about, patients I don't know, working within someone else's system, and having to review all my patient encounters. With some more knowledge, familiarity and independence, I can see 15 minute visits being enough. I wouldn't want to push it much faster than that, as I know some physicians do, but a snail's pace doesn't seem like a great idea either.

5) The Happiness Test
This question worried me a bit for this rotation because I've become fairly set on Family Medicine, but to my relief I'd say yes, they are. The paperwork seems fairly excessive and physicians who get caught up in the daily grind seem a bit disheartened, but there's room for a diverse practice to balance things out. The favourable job market and wide flexibility of location are helpful as well - where you work and who you work with matter significantly in terms of being happy at work. I think I'll welcome having a little bit of choice when I eventually establish a practice.

Medical Blarg - Where to Start

Despite my best efforts, this blog is getting a bit more readership, so I figure it's time to get some things organized around here. This post is meant to be a place to start for new readers at various points in training. My posting thus far has not been organized, so the posts don't necessarily flow into each other, but they should give you a sense of who I am and the opinions I hold.

This is also my opportunity to encourage those lurking around to comment on posts. I never really intended this blog to get much readership, but there's a reason it's a publicly-accessible blog and not a private journal. I want feedback on the things I write! Especially for those who might disagree or have a contrasting opinion to offer, I'd love to hear it.

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For Those Considering Medicine
Back Up Plans
You Should Study Something You Enjoy

For Those Applying to Medical School
On Giving Advice About Medical School Admissions
Should You Study Medicine Abroad?
If I Don't Study Medicine Abroad, What Are My Options?

For Those Trying to Choose a Specialty
How To Pick A Specialty
Preparing to Match in CaRMS (Before Knowing What To Match Into)
How To Pick A Specialty - A Follow-up

My Likes and Dislikes in...
     OB/GYN
     Pediatrics
     Emergency Medicine
     Oncology
     Internal Medicine
     Psychiatry
     Family Medicine
     Radiology
     Surgery
     Anesthesiology

My Thoughts on Medical Education
Fairness in Medical School Admissions
What Should Medical School Admissions Look Like? (Part I)
What Should Medical School Admissions Look Like? (Part II)
Med School Curriculums Across Ontario
Underpants Gnome Theory of Medical Education

Miscellaneous
Reading About Healthcare
It's Alright to Hate Medical School

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Ultimately this is a personal blog, more like an open diary than anything else, so I post about whatever comes to mind. This is how I express and reflect on my random thoughts.

I find in medicine it's too easy to get stuck on autopilot, or to feel caught on whatever treadmill I've put myself on. This blog is my effort to turn off the autopilot, to step off the treadmill if only for a few minutes.

What I hope for those who stumble across this blog is that you'll leave with something to think about, even if that thought is "wow, that guy was totally wrong!"

Happy reading!

How To Pick A Specialty - A Follow-up

It's been a bit less than a year since I made this post about picking a specialty, where I described the approach I took to narrowing down my specialty choice. Now that I'm done the majority of clerkship and am coming around to a final decision, I figure now's a good time to follow-up on that post to reflect on where my approach worked and where it might have fallen flat.

At the end of second year, my list of specialties, in no particular order, looked like this:

Diagnostic Radiology
Emergency Medicine
Family Medicine
Internal Medicine
Nuclear Medicine
Obstetrics & Gynecology
Pediatrics
Physical Medicine & Rehabilitation

Now, it's a bit smaller and it has an order:

1. Family Medicine
2. Pediatrics
3. Emergency Medicine
4. Psychiatry
5. Radiation Oncology

Two things to mention. First, a number of specialties dropped off my list. Two fell off because of less-than-great experiences in clerkship (OBGYN, Internal Medicine). A few fell off due to attrition - I didn't necessarily have bad experiences with these specialties, but I had enough good experiences in other specialties to feel comfortable eliminating them. That's all in keeping with my original strategy for picking a specialty.

Secondly, and decidedly not in keeping with my original strategy, you'll notice two specialties that weren't on my list from a year ago. I had a really good experience in Psychiatry, which I wasn't expecting. I also had a great experience in Oncology, which I was expecting, but even then the rotation exceeded my expectations.

Many residents and clerks say that you really won't know where you stand on a specialty until you experience it. I'm inclined to agree.

Nevertheless, I think my approach still has some merit. My top three specialties are ones I was considering heavily prior to clerkship. The specialties that jumped onto my list aren't overly competitive - if I wanted to, I could still make myself a reasonably attractive candidate for these fields by re-arranging electives, doing side projects, etc. Eliminating a good number of specialties because of more superficial attributes (hours, patient population, job market) proved reasonably useful because at the end of the day, they still factored into my final ordering. Radiation Oncology, for example, fit my preferences extremely well. However, its job market is pretty bad and flexibility of location is rather limited. Despite defying expectations and making my short-list, it's at the end of that list and will not factor into my elective planning.

Still, I did give too my credence to reputation about specialties, Psychiatry in particular. It hit my goals for those lifestyle-focused parameters, yet I wrote it off prematurely due to perception of the practice rather than reality. I wish I had explored it more thoroughly in advance of clerkship. It's important not to pre-judge the actual practice of a specialty until you see it first-hand.

Opiates and the Flexibility of Practice

Depending on who you ask, opioids are anywhere from the worst drug you could possible prescribe, to a necessary evil, to the best shot at treating a lot of suffering patients.

Opioid addictions are, sadly, quite common. They're also quite dangerous, with opioid-related deaths on the rise. They have some nasty side-effects. They're also becoming a mainstay of low-level criminal activity.

And worst of all, they don't seem to be all that effective. Perhaps there's a selection bias, but I haven't met too many patients who had good pain control on large doses of narcotics - a few who seem to do alright on small amounts, usually low-intensity narcotics like Tramadol. Undoubtedly there's some sampling bias there, plus those with greater pain may require stronger opioids. However, I've yet to really see strong opioids as being a satisfying answer to chronic pain.

At this stage in my career, I've seen a few different attitudes towards narcotic prescription, underlining the fact that there really is no established standard for their use, and highlighting that I may have a lot of leeway to dictate my own prescribing tendencies when I eventually have to make these calls myself. I'm nowhere near a finalized or even satisfying answer to the question "when should I prescribe opioids, and how?", but here are my initial thoughts.

1) Have an exit strategy
I've yet to see a glaring example of someone callously giving a patient an opioid addiction, but plenty of examples of a physician setting a patient to develop one incidentally. Narcotics are insidious in the way they trap patients and providers - a short run of narcotics gets extended, or a small dose gets increased, over and over again, until the patient is on long-term, high-dose opioids. It's far too easy for patients to believe that they need a higher dose and for physicians to see no good alternative to providing it.

Therefore, I think it's essential to have an endgame in mind when starting or increasing narcotics. If there's no timeline to how or when an opioid prescription will be ceased, then the snowball towards higher doses seems to be pretty difficult to avoid. In some cases, the "how and when" narcotic use is ceased will come with the death of the patient. That can absolutely be a valid exit strategy. However, for the large number of individuals who aren't meant to die on these medications, I'd like to have a plan to stop the medications

2) Use concurrent therapy
Opioids aren't a long-term solution to most pain. They certainly don't do anything to cure pain, only to (temporarily) mask it. However, they can relieve it for a time while other factors play out, so they do have a role. In many cases, time itself is a cure. In others, a more active approach is necessary. Even when there aren't treatable physical symptoms, mental health is an important component to address. Pain can practically go away when patients are happy and have a positive attitude. It can become crippling when despair sets in. Mental health issues might not cause pain (with some exceptions...) but it can be a meaningful modifier. At this point, I don't see much value in starting opioids if there aren't other avenues being actively explored.

3) Consider weening patients off opioids
In the simple case of one patient with one provider, opioid prescribing seems very straight-forward. However, medicine's a team sport and that means not everyone plays the same way. It's very common for patients to get started on opioids by a provider they'll never see again, or who will pass on responsibility for pain management before it's properly managed. Presumably, that initiator of the opioid didn't have an exit strategy or sufficient concurrent therapy, but that shouldn't excuse inaction on your part as the now-responsible prescriber.

Opioids don't have a good evidence-base behind their long-term usage. If a patient is on opioids for an extended period already, without sufficient response, doubling-down by increasing or even maintaining their opioid dose isn't likely to help. It's worth a trial ween. It's not going to help their pain - and will increase it in the short term - but it could save them from a number of side-effects and allow the patient (and you) to focus on more effective interventions.

Anyway, opioid use in medicine in a deep, complex problem without an easy solution. You'll find similar opinions from many individuals and groups in medicine. You'll also find many opposing views from individuals and groups in medicine. I don't claim to have any novel insight into this problem. However, these decisions will be my responsibility reasonably soon, so it's time to start forming a practical approach.

Dogs and Random Encounters

I have a rather energetic dog, who needs a lot of walking. Inevitably, he meets other dogs on these walks. I then meet a fair number of other owners. Not all of them I particularly want to talk to, but most are good for a conversation and it's a great opportunity to get some perspective on life outside of medicine.

I've had the good fortune of meeting a few people who have physicians in their lives, including some physicians I've met through medical school. It's been very revealing to get an outside perspective about the benefits - and challenges - of being a physician. In particular, I've appreciated hearing the effects of the career on the physician's family. Medical training is tough on the person going through it, but I'd argue it's just as tough if not tougher on their family. Some of these conversations have been good reminders that I'm not in this alone and that I need to consider the effects my career is having on those around me, particularly my partner through all this.

It also touches on a central criticism I have about medicine as a discipline - we're too separated from the patients we serve. Most physicians come from wealthy families, went straight from the academic bubble to the bubble of medicine, and then end up as a reasonably wealthy physician. Physicians live in nice but expensive neighbourhoods, their kids go to good schools (often private schools), while their vacations and hobbies are often pricey and/or eccentric. A typical physician has little free time and few intrinsic ways to interact with those not in healthcare or not at a high socioeconomic level.

Yet, people of all backgrounds own dogs. And through my dog, I get to meet a lot of them, even as I'm knee-deep in the muck of medical training. It's not much and I don't feel nearly as grounded in my community as I did before medicine (or at least before clerkship), but it's better than nothing. This is one of the many reasons I'm thankful for my furry companion.

Commuting

I'm doing an out-of-town elective for the next little while, and that means it's time for some commuting!

I expected the extra travel time to be a bit of a drain, but it's turned out reasonably well. Because of where I live, it's almost faster for me to travel cross-country to get to another city than it was to get to the main hospital where most of my clerkship rotations are held. A good part of that is because I save 10 minutes in parking time, thanks to a rather full parking garage that greets me even when I show up at 6 am.

Plus the drive is so much more enjoyable through the countryside than it is through the city, particularly in the spring. Nicer views, less traffic. Even with a fair number of tractors on the road, it's a much more predictable, manageable commute.

I'm virtually all-in for Family Medicine now, so the main questions now are where to do residency, where to ultimately practice, and what that practice should look like. I'm pretty ambivalent about the rural vs urban divide, so getting as much of the experience as possible in both settings is a goal for me at this stage. Right now, +1 for rural/semi-rural for the commute (though that'll probably change in the winter...)

Things That Are Important - Sleep Hygiene

So, sleep is kinda important. It helps you do things like be productive at work, enjoy life (in general), and to not go ballistic on a regular basis because you're too tired to be nice to people.

One thing from clerkship that has been a genuine surprise is how often I talk about sleep hygiene. I'm on my family rotation right now and it's a regular occurrence. However, that was also the case in Psychiatry and Internal and Pediatrics as well. Ironically I think my main training on sleep hygiene consisted of a few off-hand comments by a preceptor who really cared about sleep for their patients.

Maybe it's because physicians generally have terrible sleep hygiene, but it's something that doesn't seem all that emphasized in our training. Yet, it's arguably an area of lifestyle improvement we could have a large effect on, because unlike diet, exercise, and substance use, people with poor sleep are usually pretty motivated to get better sleep. No one likes being tired. It's also an area with fewer fad approaches (though that's starting to change...). As we slowly start to incorporate more lifestyle interventions into our education and practices, I'd like to see sleep take a more prominent position. It's a very easy way to improve patients' lives.