Home Call

Got my first real taste of home call this week.

So far my experience has been with in-hospital call, which is a bit more onerous, but also a bit more predictable. I lucked out and got a very light call shift this time around, basically never getting called in. The previous shift was hectic, going until late at night. If home call was just bad-vs-good shifts, I wouldn't be concerned, since who's really going to complain about a light workday, especially when you get to spend much of it at home? Well, home call means no guaranteed post-call day. If the home call turns out to be light, or at least not horribly bad, it means a full day the next day.

I hate that level of uncertainty. I really like to know when I'm showing up and roughly when I'm leaving. If an extraordinary situation occurs, then of course I'll stay longer and I come in early when I think it will help. Yet, sitting around not knowing whether or not I'll have to rush into hospital, not knowing when I'll get to go home once I'm there, not knowing how long I'll get to sleep, not knowing whether I have the next day off to rest.

In-hospital call isn't exactly enjoyable, but at least I'm aware of what's coming. I expect to be up all or most of the night. Any sleep is bonus. I expect a day off the next morning.

I'm starting to realize that while I do want a specialty with shorter hours, consistent hours might be more important. It's hard to plan your life when your time truly isn't your own and the scope of your obligations change on a whim.

Likes and Dislikes in Radiology

Finished up a rotation in Radiology, a specialty which is in many ways a natural fit for me. I knew going into this rotation that it wasn't going to be a field I was ultimately interested in, as I had thoroughly explored it in pre-clerkship, but it is still a specialty that I have a definite affinity for. Nevertheless, here are my take-aways from my Rads rotation.

1) Imaging is great for learning, especially anatomy

At my school, radiology is thrown into our surgical core rotation as a selective, which sounds somewhat odd, but I found fit quite nicely. Imaging is a big part of most surgical practice and is excellent for learning the finer points of anatomy. Particularly for those who need to visualize anatomy to understand it well, diagnostic imaging provides an opportunity to look inside the human body safely in an applied fashion. I've long thought we should be learning more anatomy off diagnostic images rather than cadavers, especially since most medical students will spend far more time looking at imaging than at dissected bodies. The rotation was a decent way to brush up on anatomy for the rest of my surgical block, where that knowledge is kind of important!

2) More patient interaction than expected, still not enough

The common assumption about Radiology is that they never see a patient, and this isn't quite true. Interventional Radiology has quite a bit of patient contact. Even those not in Interventional Radiology can interact with patients reasonably often, through biopsies or other image-guided procedures.

However, there is still a lot of time in dark rooms looking at imaging. That's tough for me to swallow. I like looking at images. I'm even ok with dark rooms! But what I enjoy about medicine is talking to patients, particularly when I get to be a part of patient education. That's not really a focus in Radiology, even in IR. It's a great fit for those who want some patient contact but who are perhaps more interested in human pathology (and how the physics of imaging interact with that pathology). Might not be the best fit for me though.

3) It's tough to be a student

Radiology is not the greatest place to be a student. I had great preceptors, but when their job mostly consists of looking at pictures and giving an interpretation, there's not a whole lot I can do to contribute or even participate. I tried to read the images as best I could to test my own eye and knowledge, which worked reasonably well to keep myself engaged, but with the diversity of images out there, I could only scratch the surface of "that looks weird" in many cases, despite having a background in imaging. It takes time and methodical practice to reach anything close to competence in image interpretation, which isn't really available in a 2 week rotation.

Those on longer rotations and those doing multiple electives would likely get some more in-depth experience, and of course residents are considerably more involved. For a 3rd year student though, it's a fairly shallow dive to be a student. Though on the plus side, they gave me plenty of time off to do independent reading!

4) The Happiness Test

Radiologists seem pretty happy. The residents at my school seem to have a rather congenial relationship with each other and their staff. The staff were largely personable and approachable. They all seemed to love what they do, even when rushed. It probably didn't hurt that their hours were pretty good and all the attendings made really good money (even with the cutbacks in Ontario).

Overall it was a good rotation, with plenty of learning opportunities and good hours. It's not the specialty for me, but unlike some other specialties, I see the appeal here.

Good Intentions, Poor Results

Medicine draws in people who want to make a positive impact on their communities and the world. This, happily, leads to a good number of active, enthusiastic young individuals putting in a lot of work for others' benefit.

However, with that enthusiasm comes a degree of naivete and, particularly in the generally intelligent, capable group of students considering medicine, perhaps a bit of overconfidence. The combination of these traits has led to more than a few instances of students putting their efforts and resources towards well-intentioned, but ultimately ineffective or even detrimental activities. A fair bit of attention has been paid to one such example, the voluntourism industry.

Faulted not just as way for wealthier students to build their CVs, volunteering abroad has also come under significant scrutiny for providing far more help for students to feel like they're doing something positive than actually helping them to do something positive. Some medical schools are actively discouraging volunteering abroad due to concerns about unequal access to these opportunities, harm to developing countries from voluntourists, and comparative lack of skills development when compared to other extra-curricular activities.

However, I'm noticing a trend of closer-to-home activities that often fall into the same category of well-intentioned but ineffectual efforts to help out others. I'm talking about becoming a "founder". Often this takes the form of a student founding a club or new initiative at their undergrad school, or striking out in the community and founding a non-profit.

Just as with volunteering abroad, these are not inherently bad activities - approached properly, by the right individuals with a long-term focus, founding a club or non-profit can be an enormously enriching endeavour, both for the community and the individuals involved. However, as with voluntourism, the typical execution is far from ideal. Student founders often lack either the skill or experience to make their new organizations effective. They may not have the time to give their project the necessary attention. New clubs or non-profits may be trying to fill roles in the community already ably filled by established organizations. Or, they might be trying to fill a role that doesn't really need filling in the first place, resulting in wasted or inefficiently used resources.

I also see clubs or non-profits being started, but then fizzling as the founders transition to other activities. Those founders may have done a fine job with the organization initially, but without a long-term approach in mind or even without a decent transition plan, the next set of leaders may not be properly equipped or motivated to maintain or grow the organization. These groups then hang around in the background, consuming resources ineffectively, before ultimately fading out.

This is hardly an issue unique to students. Heck, entire charitable sectors operate off of good intentions with poor results - this is a very common, very human failing. I'm not immune to it either - a club I helped start at my school just last year looks like it could well end up folding before I even graduate, since we failed to develop enough interest in the classes below us.

Because of these outcomes, I want to encourage students trying to contribute to their community/country/world to consider joining and improving existing organizations first. Take over a club and push it forward. Volunteer at a non-profit and make it better. Get on the inside where you can lobby charities to be more efficient and more evidence-based in their work. And learn what they do right! These experiences within established institutions can be extraordinarily valuable in a student's future career, including for those who ultimately decide further down the road that it's worth starting a new group. Improving what already exists isn't as exciting as starting something new, but in many cases, it can be more meaningful for both students and communities.

CV Writing

I'm currently putting together a draft of my CV for CaRMS. It's a very surreal experience. I know CVs don't matter that much for my matching chances, but it's going to matter a bit.

It's also my first real shot at a true CV. Sure, I've written resumes before, many times. I've even called them CVs in the past. However, they were all pretty short and pretty focused. There was no broad strokes about my past accomplishments over my entire life, in no small part because the productive part of my life was rather short.

Well, now I'm a bit older and I can actually say I've done some stuff. Important stuff! Well, sorta important stuff. Mildly interesting stuff, maybe? Stuff that'll help me be a better physician, at a minimum. Right now the challenge is sorting through what's important enough to include and what's not. There are definitely some experiences Program Directors won't care about, like my job in High School (even though I did get Employee of the Month once), or that one summer I thought I could golf (I couldn't). There are some more borderline experiences that I'm debating including, typically smaller experiences that are tangentially relevant to medicine. For example, do I put down a minor leadership role that really only took a dozen hours or so of my time and largely failed to accomplish anything of note? Do I include this blog? I'm not sure!

Whether or not to include an extensive "interests" section is also giving me pause. I'm finding this especially difficult in the depths of clerkship where it seems I don't have much time for my interests, short of the easy ones like watching Netflix while pretending to study and checking hockey scores on my phone during downtime at the hospital.

Anyway, despite all the hand-wringing, it's fun to see my past work in full and makes me feel very adult, almost like a real professional. Hope Program Directors feel the same way come CaRMS time...

Ontario Residency Spot Reduction - Update

Getting word that the announced plan to reduce the number of residency spots in Ontario for 2017 has been pushed back to 2018 pending a review. Word was initially that these were to be CMG spots, a statement which then got unofficially amended to being IMG positions. Either way, if any cuts do happen, it sounds like it won't happen this year.

Obviously I wish this pause for analysis would have happened before the first round of cuts occurred for this cycle, but I guess I can't object to a better-late-than-never situation. This year's reduction in residency spots was tempered during implementation and still seems to have had some minor negative effects.

I'm not all that opposed to reducing residency spots in general. We're stretching our educational resources a bit thin as it is and there's reasonable cause to believe we have or are heading towards an oversupply of physicians. However, a straight cut to CMG spots is a fairly terrible way to go about it. CMG spots should be cut only after medical school spots get reduced. Alternatively, my preferred approach would be an elimination of IMG spots, particularly in fields with already-poor job prospects (CMG spot cuts tend to get absorbed by IMGs anyway, just in a more messy, convoluted manner).

I'm hoping this pause in reduction of residency spots signals the start of an effort to be more deliberative in human resources planning in medicine, because right now it's a bit of a mess. Far too many actors involved in the decision-making process at various steps, few with enough information to make effective choices and rarely working in conjunction with other actors. However, if this is just a pause and not part of a greater strategy, this isn't much of a win.

CaRMS Match 2016 - Further Thoughts

I've had a bit of time to digest the CaRMS results from this year, so let's dig into the numbers a bit more deeply.

1) I made some predictions... few were right.

So, back in December, I took an educated guess as to what the match rates to a person's first-choice discipline would be by specialty, restricting myself to the larger specialties where statistically-insignificant variation doesn't play to much of a role. I even set myself some conditions for success. Those predictions can be found here.

How'd I do? Eh... Let's look at the list

Exactly Right
Orthopedic Surgery
Psychiatry

Within Margin of Error
Family Medicine
Ophthalmology

Wrong
Anesthesiology
Dermatology
Diagnostic Radiology
Emergency Medicine
General Surgery
Neurology
Obstetrics & Gynecology
Otolaryngology
Pediatrics
Plastic Surgery

Crazy Wrong
Internal Medicine
Physical Medicine & Rehabilitation
Urology

I missed my guess by 3 times my margin of error (Crazy Wrong) by almost the same number of specialties I got exactly right or within my margin of error. Wow. So, Don't trust what I say on upcoming specialty competitiveness!

Ok, the real take-away here is that even in larger specialties, there's a lot of variability. I set myself some fairy narrow margins of error, but even expanding those out a fair bit wouldn't have helped all that much. I was just flat-out wrong most of the time. Predictions are hard and competitiveness in specialties are far from being consistent.

2) This year's match was competitive

No question, this year was a tougher match than previous years. Fewer people got their first choice specialty than for any match stretching back over a decade. With a few exceptions (Radiology, ENT), my guesses on specialty competitiveness were underestimates - most specialties ended up being tougher to match to than I predicted.

Some of this likely has to do with Ontario's cuts to residency programs. While the announced 25 CMG spots aren't a huge number in the grand scheme of things, especially since the final number was less than 25, there are some non-linear effects when decreasing the buffer between number of applicants and number of positions. One person missing their first choice and ending up in a lower-ranked program can displace someone else from their first choice, and so on.

A lot of the competition this year, however, has to do with specialty preferences. Surgery was popular this year, with more people selecting it as their top choice. Family Medicine was less sought-after. When applicants shift their preferences from less competitive to more competitive specialties, overall outcomes are pretty much guaranteed to decline. They did.

3) Income and job markets matter - don't they?

I'm a firm believer that when it comes to specialty choice, incentives matter. Job market, working conditions, income - all of these affect what specialties students prefer. These aren't generally definitive considerations, as few people would pick a specialty they hate over a specialty they love simply because of these extrinsic factors. However, when faced with a roughly similar appreciation for multiple specialties, which is a fairly common situation, students tend to prefer careers that give them a reliable job with decent pay and their preferred work-life balance.

On that front this year... confused me. Surgery has declined in popularity recently due to a terrible job market and generally poor working conditions, offset only by a generally good income. It got more competitive this year - not that much more competitive, but an increase nonetheless, above and beyond any loss in surgical residency spots.

Yet, PM&R - a sleeper specialty with a decent mix of pay, working conditions, and job market, saw a huge jump in interest. Derm and Emerg continue to grow in popularity, for similar reasons. Psych has maintained its gains in medical student interest.

In the middle, Family Medicine and Radiology both took some decent hits to their income in Ontario as a result of the on-going feud between the OMA and the Ontario government. Interest in those specialties declined. Yet, the decline in interest wasn't exactly confined to Ontario schools. That makes some sense for Radiology, but doesn't quite fit the trend in Family Medicine.

Basically, I'm lost. There's always some year-to-year variability in specialty interest, but we've seen some rather stable trends lately. Specialties with poor working conditions and job prospects have dropped in student interest, while more lifestyle-friendly specialties have seen their level of interest improve. That didn't exactly happen this year, but it also didn't exactly not happen - it was very much a mixed picture. Could we be seeing the limit of lifestyle effects on student specialty preferences?

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The overarching lesson here is that CaRMS matches are pretty chaotic. My year, starting the match process in really only a few months, are really at the mercy of chance and the random preferences of the rest of our cohort. Some people are going to get lucky and shoot for a specialty that is unexpectedly uncompetitive this year. Some are going to draw the short straw and will have to fight for a surprisingly in-demand position. There's no point trying to play the guessing game and picking a specialty based on competitiveness though, as I know some students would prefer to, because we mostly find this information out after-the-fact.

The recommended match strategy for everyone remains the same - pick a specialty you like, pick a back-up specialty if feasible, work hard for good LORs, apply broadly, and rank every program you would prefer matching to over going unmatched. That doesn't change if you're going for Family Medicine or Dermatology.