Syrian Refugees

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

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

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

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

Vacation Sick, Once Again

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

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

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

Combating Depression in Medical Trainees

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

1) Reduce Hours

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

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

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

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

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

2) Orientation and Role Definition

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

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

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

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

3) Allow Greater Flexibility in Education

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

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

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

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

4) Just Treat Each Other Better!

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

5) Wellness Programs

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

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

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

CaRMS Update - Interviews

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

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

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

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

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

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

Depression in Medicine

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

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

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

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

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

Bucket List

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

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

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

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

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

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

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

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

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

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

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

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

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

Likes and Dislikes - Physical Medicine and Rehabilitation

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

1) Welcome to the Team

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

2) I Forgot Stuff... Lots of Stuff

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

3) Competitive

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

4) Happiness Test

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