A physician in clinic recently commented on how difficult it is to do research in many areas of medicine as a very positive reflection on how far medicine has come. In a surprising number of circumstances, truly bad outcomes are rare enough that discerning the effect of any one intervention of those outcomes requires a massive sample size.
This brings me back to my pre-medicine days when I did some work on the negative effects of radiation from diagnostic imaging. It's incredibly difficult to do good research on harms caused by radiation in medicine because the main predicted harm (cancer) occurs so rarely at typical doses of radiation used, occurs way into the future making causality tough to demonstrate, and gets drowned out by the relatively high baseline risk of cancer from, well, being an alive human being long enough.
I've enjoyed my research experiences and in an ideal world, would like to continue with some research moving forward, despite going into a field not well-known for research productivity. It is a slog these days in medicine and not just because of systemic issues like funding or cumbersome ethics approval. However, a lot of these difficulties stem from prior successes. We've picked a lot of the low-hanging fruit. It's hard to discover something like penicillin with a virtually 100% cure rate for a common condition (well, until all that antibiotic resistance started popping up). Common conditions these days are often multi-factorial in etiology and while we can't cure many of them, we're not too bad at managing them to some degree of effectiveness.
Current efforts in medical research require complex and sophisticated approaches. That we can undertake that research - with at least some degree of success - shows how much research as a discipline itself has progress. That we need to undertake that research shows how much research in medicine has accomplished.
Friday 29 July 2016
Tuesday 26 July 2016
Amateur Doctor
Ok, had to share this comic.
I make this joke - or something very similar - about once a week! Helps remind both patients and other healthcare staff that I am not a physician (yet), particularly when I'm being asked about things a bit beyond my level. Also a great way to laugh off the ever-growing pile of debt and the long, unpaid workweeks.
Well, now I'm sad... back to my Amateur Doctoring, I guess!
Well, now I'm sad... back to my Amateur Doctoring, I guess!
Wednesday 20 July 2016
OMA Tentative Agreement
Quick(well, it was supposed to be quick) post for those in Ontario about the OMA's tentative agreement with the Ontario government on physician compensation. It came out of nowhere and is causing quite a bit of outrage from more than a few physicians, some directed at the government, some directed at the OMA itself.
The OMA will be holding a non-binding vote on the matter, which apparently I get to participate in, despite being a student. Based on the text of the agreement, my vote will be a definite "no" for two major reasons.
First, and you'll hear a lot about this from practicing physicians, is a lack of binding arbitration. Right now the government seems to be getting away with unilateral action. The OMA has sued to retain their right to binding arbitration, but lawsuits can be difficult to predict. Few labour laws apply to physicians and for a variety of reasons, we have no ability to undertake real labour actions. Some form of binding arbitration is about the only protection we can expect to protect our rights as workers.
Without that assurance, even if this deal proves to be acceptable in the short-term, it leaves open the door for significant long-term reductions in fees over time. Death by 1000 cuts, as it were. If that were to occur, the only recourse would be for physicians to leave the province or profession, neither of which is good for physicians, patients, or the government. I worry about physicians having too much clout over their own income and we certainly shouldn't be given free reign, but some defense against competing interests is necessary. Absent any others, binding arbitration is a deal-breaker.
Second, the Physician Services Budget (PSB) has to be eliminated. Despite all my protestations above, if I had to choose between adding binding arbitration and getting rid of the PSB, I'd choose removing the PSB. The idea behind the PSB is logical at first glance - physician billings make up nearly 10% of the provincial government and are growing at a rate faster than inflation or tax receipts. If they could be effectively capped, the government would save a significant amount of money and put itself in a much better financial situation moving forward.
The problem with the PSB is that while it provides a cap, it does not provide any mechanism for it to be achieved effectively. Expenses for physician billings go down if physicians bill for less procedures or get paid less for each billing. The PSB ostensibly gives physicians an incentive to collectively bill less, in order to avoid any clawbacks. Unfortunately, because the cap applies to physicians collectively, and each individual physician cannot change the actions of physicians as a whole, individual physicians retain the same incentives as before, namely to bill as much as possible. The PSB does nothing to reduce quantity of billing.
So, the PSB instead becomes about reducing cost per billing by using the clawback mechanism. An effort to reduce average cost per billing on its own isn't too objectionable, but the approach taken with clawbacks is where trouble occurs. The clawback hits all services equally, from services that are paid more than they should be, to ones that are undercompensated. Theoretically the new agreement includes a mechanism for the OMA to tailor any clawbacks to economic circumstances, but no details or assurances have been provided on that front. Additionally, because the clawback could be variable, it makes financial planning for physicians very difficult. It's like buying groceries, leaving the grocery store, then finding out that the price you were given in-store changed and you suddenly owe more for some or all of your items. Makes it hard to plan a food budget!
Lastly, the PSB and clawback punishes physicians for factors out of their control. The number of patients go up? Well, then physicians get paid less. Patients require more services, either because they're getting sicker or even getting the extra help they need (think mental health services especially here)? Physicians get paid less. If physicians need an income reduction because we get paid too much, or certain services are too richly compensated, I'm fine with that. It's when it happens indiscriminately and due to factors unrelated to physicians' performance or ability that I object.
Money is not a major factor for me in my career. I'm choosing a relatively low-earning career path and am quite happy with that. I wouldn't object to a reasonable reduction in my future income either, given national and international comparisons. However, the process matters and the impacts of those cuts on patients, and the financial well-being of the system, do matter.
If I do get a say on this, I will be voting "no".
Saturday 16 July 2016
Everyday Sacrifices
Becoming a physician is about making sacrifices. There are ways to mitigate, minimize, and tailor those sacrifices, but as a whole, they're unavoidable. We give up our 20's and in many cases a fair bit of our 30's to become a physician. We give up nights out partying or relaxing with friends to study, to do research or other projects, to spend long days at the hospital. We give up time with our families, or delay having a family, in order to complete our training successfully.
There's really no getting out of these aspects of medicine, they're inherent in the profession and its training.
However, we also want physicians who are willing to make additional sacrifices for the sake of their patients. Physicians who will forego a little income to provide a good service on a regular basis. Physicians who will make an extra call to get their patients the supports they need. Physicians who will stay a little longer at the end of the day for a patient in crisis. It's far too easy to phone things in in this profession, to our patients' detriment.
That said, medicine has a problem with indiscriminate sacrifice. Medicine tends to encourage and incentivize physicians giving more of themselves without considering what the sacrifice is for, or whether it is even helpful.
Two scenarios that have happened often enough jump out at me.
1) Blatant Benevolence
A play on the concept of conspicuous consumption, where people buy expensive things essentially for the sake of showing they can buy expensive things, blatant benevolence is the idea of doing something good because of the reputation it garners. The original concept was applied to mating preferences, but the term has broader applications. In medicine, that means staying late, coming in early, taking on an extra patient or doing some additional grunt work. The idea is that these actions show desirable qualities to colleagues and superiors.
The important point here is that with blatant benevolence, it's the perception resulting from the actions that matters, not the effect of the actions themselves. There are, of course, instances when coming in early, staying late, or taking on an extra patient is extremely helpful and especially at the trainee stage, most people are eager to take these opportunities to demonstrate their commitment or ability.
It's when these actions are not helpful that the profession runs into trouble. Students pre-rounding an hour before their shift starts when no one asks them to. Residents staying hours after their shift ends to watch over a patient who they've already ably handed over to the next team. Staff sticking around to handle tasks that would normally go to residents for their learning. These actions clearly show that the physician or trainee puts medicine first and foremost, but don't add value to their patients' care and could be taking opportunities away from others.
We're thankfully moving away from these pointless shows of sacrifice, but it's still very much a part of medicine. Maybe 1 in 5 trainees seem to engage in this sort of behaviour regularly, but just like with conspicuous consumption, those who do engage in it pull others with them moving forward. A decent number of trainees come in with the idea that they must show. Which brings us to the second scenario...
2) Extraordinary Actions in Ordinary Times
Physicians are the first and last line when it comes to healthcare. When something falls through the cracks, we're expected - and even have a legal obligation - to pick it up. Medicine has a lot of cracks, however, so things slip through regularly. And dutifully, physicians respond by giving up even more of their lives to help their patients.
These actions are essentially required in medicine. The notion is that these are unpredictable events and so it is up to physicians to provide the flexibility necessary to respond to them.
When the extraordinary happens on a regular basis, it's no longer extraordinary. It's no longer unpredictable. Yet physicians continue to react to these commonplace occurrences as though they're extraordinary and unavoidable.
A physician staying late once a month is totally reasonable. A physician staying late once a week is troublesome, but manageable. Yet when I see physicians - particularly residents - staying late multiple times a week, it's no longer about physicians sacrificing for their patients, it's now physicians sacrificing for a poorly-run system.
Worse, when the extraordinary does actually happen, physicians may not have the ability or willingness to make that extra effort. They're already pushed to their limits with their regular expectations. Very few physicians are truly indifferent to their patient's interests, but fatigue and burnout can mean important but non-critical tasks get delayed, ignored, or rushed.
-----
I heard an older physician remark recently that my generation of medical students doesn't know the meaning of sacrifice. Certainly, what my generation seems to prefer and tolerate differs from the expectations of some of our superiors. However, I don't consider that to be a negative. What we consider a worthwhile sacrifice needs to be refined. There are some sacrifices made by established physicians I never want to make. Yet there are other sacrifices these physicians tend to avoid that I'm eager to make. Recognizing that physicians are human, that they have their limits and in normal times should lead reasonably normal lives, we need to be smarter about what sacrifices we choose to make or to ask each other to make.
There's really no getting out of these aspects of medicine, they're inherent in the profession and its training.
However, we also want physicians who are willing to make additional sacrifices for the sake of their patients. Physicians who will forego a little income to provide a good service on a regular basis. Physicians who will make an extra call to get their patients the supports they need. Physicians who will stay a little longer at the end of the day for a patient in crisis. It's far too easy to phone things in in this profession, to our patients' detriment.
That said, medicine has a problem with indiscriminate sacrifice. Medicine tends to encourage and incentivize physicians giving more of themselves without considering what the sacrifice is for, or whether it is even helpful.
Two scenarios that have happened often enough jump out at me.
1) Blatant Benevolence
A play on the concept of conspicuous consumption, where people buy expensive things essentially for the sake of showing they can buy expensive things, blatant benevolence is the idea of doing something good because of the reputation it garners. The original concept was applied to mating preferences, but the term has broader applications. In medicine, that means staying late, coming in early, taking on an extra patient or doing some additional grunt work. The idea is that these actions show desirable qualities to colleagues and superiors.
The important point here is that with blatant benevolence, it's the perception resulting from the actions that matters, not the effect of the actions themselves. There are, of course, instances when coming in early, staying late, or taking on an extra patient is extremely helpful and especially at the trainee stage, most people are eager to take these opportunities to demonstrate their commitment or ability.
It's when these actions are not helpful that the profession runs into trouble. Students pre-rounding an hour before their shift starts when no one asks them to. Residents staying hours after their shift ends to watch over a patient who they've already ably handed over to the next team. Staff sticking around to handle tasks that would normally go to residents for their learning. These actions clearly show that the physician or trainee puts medicine first and foremost, but don't add value to their patients' care and could be taking opportunities away from others.
We're thankfully moving away from these pointless shows of sacrifice, but it's still very much a part of medicine. Maybe 1 in 5 trainees seem to engage in this sort of behaviour regularly, but just like with conspicuous consumption, those who do engage in it pull others with them moving forward. A decent number of trainees come in with the idea that they must show. Which brings us to the second scenario...
2) Extraordinary Actions in Ordinary Times
Physicians are the first and last line when it comes to healthcare. When something falls through the cracks, we're expected - and even have a legal obligation - to pick it up. Medicine has a lot of cracks, however, so things slip through regularly. And dutifully, physicians respond by giving up even more of their lives to help their patients.
These actions are essentially required in medicine. The notion is that these are unpredictable events and so it is up to physicians to provide the flexibility necessary to respond to them.
When the extraordinary happens on a regular basis, it's no longer extraordinary. It's no longer unpredictable. Yet physicians continue to react to these commonplace occurrences as though they're extraordinary and unavoidable.
A physician staying late once a month is totally reasonable. A physician staying late once a week is troublesome, but manageable. Yet when I see physicians - particularly residents - staying late multiple times a week, it's no longer about physicians sacrificing for their patients, it's now physicians sacrificing for a poorly-run system.
Worse, when the extraordinary does actually happen, physicians may not have the ability or willingness to make that extra effort. They're already pushed to their limits with their regular expectations. Very few physicians are truly indifferent to their patient's interests, but fatigue and burnout can mean important but non-critical tasks get delayed, ignored, or rushed.
-----
I heard an older physician remark recently that my generation of medical students doesn't know the meaning of sacrifice. Certainly, what my generation seems to prefer and tolerate differs from the expectations of some of our superiors. However, I don't consider that to be a negative. What we consider a worthwhile sacrifice needs to be refined. There are some sacrifices made by established physicians I never want to make. Yet there are other sacrifices these physicians tend to avoid that I'm eager to make. Recognizing that physicians are human, that they have their limits and in normal times should lead reasonably normal lives, we need to be smarter about what sacrifices we choose to make or to ask each other to make.
Thursday 14 July 2016
Pokemon Go
So... Pokemon Go is pretty popular. A good portion of my class is already hooked, as are a few attendings. I tried to resist, gave in, deleted the app, caved again a few hours later and am now officially hooked as well.
I've seen so many people walking around semi-aimlessly playing this game. It's great, because a lot of people are getting some extra exercise. However, it's only a short amount of time before someone kills themselves playing this game, probably by stepping in front of a car, or crashing one themselves.
It's been a huge advantage for me to have a dog while playing Pokemon Go. Guy walking around a neighbourhood aimlessly while constantly looking at his phone? Weird at best, suspicious for something nefarious at worst. Guy walking around a neighbourhood aimlessly while constantly looking at his phone with a dog? Totally acceptable!
Kinda interested to see the evolution of this medium - Go is a pretty simple game all things considered, there's lots of potential for refinement. Social implications here are significant too. As much as the internet has shaped how we interact with and perceived each other, more sophisticated augmented reality products could drastically alter how we view the world and each other.
For now though, I'm going to keep hunting the Squirtle that hangs out near my house!
I've seen so many people walking around semi-aimlessly playing this game. It's great, because a lot of people are getting some extra exercise. However, it's only a short amount of time before someone kills themselves playing this game, probably by stepping in front of a car, or crashing one themselves.
It's been a huge advantage for me to have a dog while playing Pokemon Go. Guy walking around a neighbourhood aimlessly while constantly looking at his phone? Weird at best, suspicious for something nefarious at worst. Guy walking around a neighbourhood aimlessly while constantly looking at his phone with a dog? Totally acceptable!
Kinda interested to see the evolution of this medium - Go is a pretty simple game all things considered, there's lots of potential for refinement. Social implications here are significant too. As much as the internet has shaped how we interact with and perceived each other, more sophisticated augmented reality products could drastically alter how we view the world and each other.
For now though, I'm going to keep hunting the Squirtle that hangs out near my house!
Monday 11 July 2016
Surgery in the Summer
Surgery in the summer is a bit of a different beast compared to surgery in the rest of the year.
There's less OR time, more people are on vacation, the sun is out most of the day, there's no snow. Days are a bit shorter since there are fewer patients to round on. Even when the hours are pretty long, the warm weather and sunshine somewhat counter-acts the never-ending exhaustion. The balance of responsibilities shifts away from being in the OR to doing consults or clinics.
The downside is that experiences are a bit limited. There's not always enough ORs, consults, or clinics to go around. Surgeries that do happen tend more towards the emergent or urgent, as elective procedures get deferred to the fall when OR time increases.
For those with no interest in becoming a surgeon - like me - it's a pretty good deal. There's a decent amount of time for studying and less time standing in an OR seeing procedures I'll never participate in again. A bit more learning for my long-term career interests, less of a service component. Had some decent impromptu teaching as well, tailored to my career interests. For those who are seriously considering surgery, it's a time to avoid. Too few opportunities to shine or get hands-on learning with direct relevance to a career in the OR. Lots of sharing of experiences with other students, given limited work to do. Physicians are on vacation all the time, meaning few chances to spend more than a week with a single physician, and less time to impress any one of them.
Hard to do much about this when your clerkship schedule is already set, as it is for most people starting their 3rd year in September, but something for me to keep in mind when it comes to planning electives and/or setting up rotations for my residency. To survive surgical rotations, pick the slow times; to thrive, busier times are better. As a non-surgeon, I'm happy with survival.
There's less OR time, more people are on vacation, the sun is out most of the day, there's no snow. Days are a bit shorter since there are fewer patients to round on. Even when the hours are pretty long, the warm weather and sunshine somewhat counter-acts the never-ending exhaustion. The balance of responsibilities shifts away from being in the OR to doing consults or clinics.
The downside is that experiences are a bit limited. There's not always enough ORs, consults, or clinics to go around. Surgeries that do happen tend more towards the emergent or urgent, as elective procedures get deferred to the fall when OR time increases.
For those with no interest in becoming a surgeon - like me - it's a pretty good deal. There's a decent amount of time for studying and less time standing in an OR seeing procedures I'll never participate in again. A bit more learning for my long-term career interests, less of a service component. Had some decent impromptu teaching as well, tailored to my career interests. For those who are seriously considering surgery, it's a time to avoid. Too few opportunities to shine or get hands-on learning with direct relevance to a career in the OR. Lots of sharing of experiences with other students, given limited work to do. Physicians are on vacation all the time, meaning few chances to spend more than a week with a single physician, and less time to impress any one of them.
Hard to do much about this when your clerkship schedule is already set, as it is for most people starting their 3rd year in September, but something for me to keep in mind when it comes to planning electives and/or setting up rotations for my residency. To survive surgical rotations, pick the slow times; to thrive, busier times are better. As a non-surgeon, I'm happy with survival.
Friday 1 July 2016
July Has Arrived
I'm deep into my surgical rotation now, so posting is down a bit - but I lucked into a full long weekend off, so perhaps I can pick up the pace a bit!
It's now July and that means a lot of changes in academic hospitals. Residents' years run from July 1st to June 30th, so today represents a big milestone for many people. Residents who are in their final year have officially just finished the most important part of their training and are going onto fellowships or into the working world. Other residents are moving up into new roles or new positions within their residency program.
In addition, the new residents are starting today. Obviously an exciting time for them, but it's interesting to see the wariness the rest of the hospital staff have towards this new transition. The July Effect, the worsening of outcomes in academic hospitals, provokes enough anxiety among senior residents and nursing staff. The evidence for patient harm in July is a bit conflicted, but the nurses certainly seem to believe that their lives are going to get harder starting today, as the seasoned PGY1s move onto their second year and get replaced with fresh new residents who may have been out of hospital for months. Many will be coming from other schools or even other countries and won't be familiar with the way our hospitals work. The new residents have the least experience of anyone in their position, yet the same level of responsibility.
I expect it will be a change for us clerks too. We've now been in the hospital for 10 months straight and know our role pretty well. We're only a year from starting residency ourselves. When we started clerkship, even the most junior resident was two years ahead of us in training and had a few months under their belt. When I start back on Monday, the training gap closes to a year while the incoming residents will still be adjusting to their new roles and surroundings. We're not at a resident level yet, but the gap between us and our residents will probably never be smaller.
I'm interested to see how the dynamic changes over the next few months!
It's now July and that means a lot of changes in academic hospitals. Residents' years run from July 1st to June 30th, so today represents a big milestone for many people. Residents who are in their final year have officially just finished the most important part of their training and are going onto fellowships or into the working world. Other residents are moving up into new roles or new positions within their residency program.
In addition, the new residents are starting today. Obviously an exciting time for them, but it's interesting to see the wariness the rest of the hospital staff have towards this new transition. The July Effect, the worsening of outcomes in academic hospitals, provokes enough anxiety among senior residents and nursing staff. The evidence for patient harm in July is a bit conflicted, but the nurses certainly seem to believe that their lives are going to get harder starting today, as the seasoned PGY1s move onto their second year and get replaced with fresh new residents who may have been out of hospital for months. Many will be coming from other schools or even other countries and won't be familiar with the way our hospitals work. The new residents have the least experience of anyone in their position, yet the same level of responsibility.
I expect it will be a change for us clerks too. We've now been in the hospital for 10 months straight and know our role pretty well. We're only a year from starting residency ourselves. When we started clerkship, even the most junior resident was two years ahead of us in training and had a few months under their belt. When I start back on Monday, the training gap closes to a year while the incoming residents will still be adjusting to their new roles and surroundings. We're not at a resident level yet, but the gap between us and our residents will probably never be smaller.
I'm interested to see how the dynamic changes over the next few months!
Subscribe to:
Posts (Atom)