So my CaRMS tour has begun and is actually nearing an end. I've only got a single interview left. The Rank Order Lists are available and I've submitted my tentative list. (Side note - submitting a preliminary list is very much worthwhile, as no ROL means no match at all, while a bad ROL still gives you a chance at something. ROLs can always be changed, as I suspect my tentative list will be after I finish my last interview).
I obviously can't say much about the interviews themselves, but I will note that the preparation offered by official groups (my school, the CMA, CFMS) have all been quite helpful. I would highly recommend accessing as many available resources from official sources as possible and sticking to that available prep material seemed to be sufficient.
I say seemed to be sufficient because obviously I have no idea how well I did in my interviews. They seemed to go fairly well. They've been universally relaxed and conversational, which may be a factor of being Family Medicine interviews more than anything else. In my case, they've also been unbelievably quick, and I'm not quite sure what to make of that. I answered all the questions I was given reasonably thoroughly, my interviewers seemed happy enough with my answers, but the interviews have all felt like whirlwinds once they were done. It's impossible to know how well interviews went, so I'm just going to hope my speed was not a detriment to my evaluation.
In any case, I've got one last interview to show what I can bring to a residency program, a few weeks to finalize my ROL, and then a month to sit around and stress about the match results! Fun times ahead...
Saturday 28 January 2017
Tuesday 24 January 2017
The OMA and Job Action
Once again, the Ontario Medical Association is proving to be far more, ahem, entertaining than a physicians' advocacy group should be. This time around, the entire OMA Executive Committee is facing removal by the rest of the OMA Council, citing a litany of objections to actions taken before, during, and after the tPSA debacle.
Since the tPSA was rejected by OMA members, the OMA itself has tried to do an about-face and has essentially been on the warpath against the Liberal government, after having spent the previous period of time aggressively selling the tPSA as an acceptable arrangement. It's been... an interesting transition. Don't get me wrong, the OMA was never exactly buddy-buddy with the provincial government, but the public releases went from relatively civil, responsive, boring politically-minded messaging towards something more reactionary and, at times, rather vitriolic.
Anyway, the OMA's Executive Committee is on the block now and may or may not be removed from their positions. It's up to the OMA Council. I'm not sure what a good outcome from here will look like. I think the OMA would have been best served if the Executive Committee had resigned after the tPSA and transitioned their responsibilities to individuals who could straddle the line between the "pro" and "con" side of the tPSA debate a bit better. That said, since the tPSA my feelings of the OMA's actions have been mixed, with some positives in with the negatives, so I do worry that forcefully throwing out the current Executive Committee will result in a less experienced and capable group that takes things too far the other way.
There is one issue in this recent debacle I do put a high emphasis on - the prospect of Job Action by physicians. The OMA, pursuant to the strategy recommended by the various legal and PR firms they've consulted, has put Job Action on the table to push the government for a better deal. This terrifies me. In an era where many people feel they don't earn enough for the work they do, physicians' six-figure incomes are an easy target. The most palatable argument against cutting those salaries, or at least restricting the cuts to the higher earners among us, is that physicians work their butts off for their patients to earn that high salary. The second physicians stop working and put patient care second to compensation demands, we've lost any chance at real public support. It didn't work well the last time it was tried in the 90's and I have no reason to think it would be any better this time.
Critically, any sort of Job Action would undoubtedly have a negative effect on patients. Regardless of what it might do to improve our negotiating position, putting ourselves first by putting patients second is a line that should not be crossed under any normal circumstances. Even with the unilateral cuts, physicians are still doing reasonably well from a financial standpoint and nothing the Ontario government has done comes close to justifying compromising patient care.
Worryingly, I have no idea what any new OMA Executive Committee would push for on this front. Of the many perceived faults detailed by those trying to remove the current Executive Committee, pushing for Job Action isn't one of them. It's a surprisingly popular idea by physicians, on both sides of the debate. It's far too easy for physicians of all stripes to overestimate how well they're liked and how much support we have in any fight over money. Job Action is a high-risk, high-reward approach that bets that the Ontario government would face more scrutiny than physicians, with little evidence that this would be the case.
Whatever the outcome of the OMA's internal power struggle, I'm hoping Job Action gets taken off the table permanently, both for our sake and for the sake of Ontario's patients.
Since the tPSA was rejected by OMA members, the OMA itself has tried to do an about-face and has essentially been on the warpath against the Liberal government, after having spent the previous period of time aggressively selling the tPSA as an acceptable arrangement. It's been... an interesting transition. Don't get me wrong, the OMA was never exactly buddy-buddy with the provincial government, but the public releases went from relatively civil, responsive, boring politically-minded messaging towards something more reactionary and, at times, rather vitriolic.
Anyway, the OMA's Executive Committee is on the block now and may or may not be removed from their positions. It's up to the OMA Council. I'm not sure what a good outcome from here will look like. I think the OMA would have been best served if the Executive Committee had resigned after the tPSA and transitioned their responsibilities to individuals who could straddle the line between the "pro" and "con" side of the tPSA debate a bit better. That said, since the tPSA my feelings of the OMA's actions have been mixed, with some positives in with the negatives, so I do worry that forcefully throwing out the current Executive Committee will result in a less experienced and capable group that takes things too far the other way.
There is one issue in this recent debacle I do put a high emphasis on - the prospect of Job Action by physicians. The OMA, pursuant to the strategy recommended by the various legal and PR firms they've consulted, has put Job Action on the table to push the government for a better deal. This terrifies me. In an era where many people feel they don't earn enough for the work they do, physicians' six-figure incomes are an easy target. The most palatable argument against cutting those salaries, or at least restricting the cuts to the higher earners among us, is that physicians work their butts off for their patients to earn that high salary. The second physicians stop working and put patient care second to compensation demands, we've lost any chance at real public support. It didn't work well the last time it was tried in the 90's and I have no reason to think it would be any better this time.
Critically, any sort of Job Action would undoubtedly have a negative effect on patients. Regardless of what it might do to improve our negotiating position, putting ourselves first by putting patients second is a line that should not be crossed under any normal circumstances. Even with the unilateral cuts, physicians are still doing reasonably well from a financial standpoint and nothing the Ontario government has done comes close to justifying compromising patient care.
Worryingly, I have no idea what any new OMA Executive Committee would push for on this front. Of the many perceived faults detailed by those trying to remove the current Executive Committee, pushing for Job Action isn't one of them. It's a surprisingly popular idea by physicians, on both sides of the debate. It's far too easy for physicians of all stripes to overestimate how well they're liked and how much support we have in any fight over money. Job Action is a high-risk, high-reward approach that bets that the Ontario government would face more scrutiny than physicians, with little evidence that this would be the case.
Whatever the outcome of the OMA's internal power struggle, I'm hoping Job Action gets taken off the table permanently, both for our sake and for the sake of Ontario's patients.
Friday 20 January 2017
What Makes Me Happy About Being In Medicine
In this blog, I'm fairly critical of the medical profession, medical education, and the healthcare system in general. I've mentioned before that this critical view of my own field comes from a deep-seeded optimism - I think what physicians and other medical professionals do is important, but that we can be doing a much better job by changing our attitudes and approaches. I want us to do better and through this journey so far, I've been rather dissatisfied by how poorly we often do.
Yet, despite some very real times of darkness, there's a lot I actually enjoy about medicine. I don't talk about these enjoyable aspects enough. So, this is what makes me happy about being a future physician.
1) Working with people at their lowest
Everyone goes through some hardship. Some more than others, unfortunately. It's how we handle and recover from those hardships that seems to determine how the sum of our lives turn out. I really enjoy helping people through these hardships, sometimes with drugs and procedures, but usually just with a few well-placed words of clarity and optimism. There are definitely other vocations where a person can do this, but few where these situations come up so regularly and few where you can be so comprehensive in your interventions. I realize this is a version of the cliché “I just like helping people” diatribe which I find horribly overplayed in medicine, so my bit of nuance is that I don't find as much enjoyment from treating patients who are the sickest, but rather that I gain a lot of satisfaction to talking to people who are the most scared. We don't focus on these conversations much in medicine, but they're integral to the job and I'm grateful to be able to have those talks.
2) Learning about human bodies
Medical students love studying the human body. Anatomy, physiology, pathology – interesting stuff, right? Not to me. Ok, it's interesting in its own way, but more in the way reading an encyclopedia is interesting. Plus, it’s not something you need a medical degree to learn about. Anyone can buy an anatomy textbook, read up on human physiology or delve into the various pathologies that people suffer from. What I like learning about is the massive variations – and similarities – in human bodies in real life.
Most people keep their bodies very private and grant few the privilege to see beyond what they show publicly. As a future physician, I'm granted that privilege on a regular basis as a matter of profession, by complete strangers who only know me as a medical student. Despite working in healthcare previously, it's been eye-opening to see how distorted my perception of what a typical human form looks like and how it changes as we age. In a society that places enormous emphasis on physical appearance, I find this new perspective invaluable. I'm thankful for the professional standards of my peers and predecessors, which I am also now tasked with upholding, who worked to earn this trust that now extends to me.
3) Freedom of communication
I worked in healthcare before entering medical school and one of the most frustrating aspects was that I was absolutely forbidden, by hospital policy, college regulations, and law, from providing diagnoses to patients. Even if that diagnosis was written in their chart and they weren't aware of it yet, I couldn't speak. I remember so many scared patients simply looking for an answer and I couldn't do a thing to help aside from vague reassurances. Even as a medical student, I now have more power to earnestly and openly communicate with my patients than I did as a different fully-certified healthcare professional. I find some physicians don't always respect this authority, having never had to work in medicine without it, but it's an enormous freedom. The healthcare system can be quite complex and bureaucratic, made worse by the wall of silence most non-physicians have to put up when interacting with patients. Physicians are some of the few practitioners that can cut through this bureaucracy if they are proactive and considerate. I consider this an enormous benefit to being in medicine as a profession.
4) The rare, incomparable wins
If medicine can be compared to a sport, it involves a couple of tight wins, a few catastrophic losses, and a whole lot of ties. Every once in a while, however, there are some unambiguous wins. They're not common - experiencing one once a month or means things are going pretty well. When they occur, however, they're fairly memorable. There's one moment from early in my clerkship experience that, while I can't talk about it publicly, even semi-anonymously on this blog, that I will never forget. When going through the roughest aspects of training, or of the job itself, these moments are soul-saving memories, a reminder that while most of what physicians do isn't all that consequential, sometimes can be exceedingly consequential. It's the best argument I have for pushing through all the muck in medicine.
Yet, despite some very real times of darkness, there's a lot I actually enjoy about medicine. I don't talk about these enjoyable aspects enough. So, this is what makes me happy about being a future physician.
1) Working with people at their lowest
Everyone goes through some hardship. Some more than others, unfortunately. It's how we handle and recover from those hardships that seems to determine how the sum of our lives turn out. I really enjoy helping people through these hardships, sometimes with drugs and procedures, but usually just with a few well-placed words of clarity and optimism. There are definitely other vocations where a person can do this, but few where these situations come up so regularly and few where you can be so comprehensive in your interventions. I realize this is a version of the cliché “I just like helping people” diatribe which I find horribly overplayed in medicine, so my bit of nuance is that I don't find as much enjoyment from treating patients who are the sickest, but rather that I gain a lot of satisfaction to talking to people who are the most scared. We don't focus on these conversations much in medicine, but they're integral to the job and I'm grateful to be able to have those talks.
2) Learning about human bodies
Medical students love studying the human body. Anatomy, physiology, pathology – interesting stuff, right? Not to me. Ok, it's interesting in its own way, but more in the way reading an encyclopedia is interesting. Plus, it’s not something you need a medical degree to learn about. Anyone can buy an anatomy textbook, read up on human physiology or delve into the various pathologies that people suffer from. What I like learning about is the massive variations – and similarities – in human bodies in real life.
Most people keep their bodies very private and grant few the privilege to see beyond what they show publicly. As a future physician, I'm granted that privilege on a regular basis as a matter of profession, by complete strangers who only know me as a medical student. Despite working in healthcare previously, it's been eye-opening to see how distorted my perception of what a typical human form looks like and how it changes as we age. In a society that places enormous emphasis on physical appearance, I find this new perspective invaluable. I'm thankful for the professional standards of my peers and predecessors, which I am also now tasked with upholding, who worked to earn this trust that now extends to me.
3) Freedom of communication
I worked in healthcare before entering medical school and one of the most frustrating aspects was that I was absolutely forbidden, by hospital policy, college regulations, and law, from providing diagnoses to patients. Even if that diagnosis was written in their chart and they weren't aware of it yet, I couldn't speak. I remember so many scared patients simply looking for an answer and I couldn't do a thing to help aside from vague reassurances. Even as a medical student, I now have more power to earnestly and openly communicate with my patients than I did as a different fully-certified healthcare professional. I find some physicians don't always respect this authority, having never had to work in medicine without it, but it's an enormous freedom. The healthcare system can be quite complex and bureaucratic, made worse by the wall of silence most non-physicians have to put up when interacting with patients. Physicians are some of the few practitioners that can cut through this bureaucracy if they are proactive and considerate. I consider this an enormous benefit to being in medicine as a profession.
4) The rare, incomparable wins
If medicine can be compared to a sport, it involves a couple of tight wins, a few catastrophic losses, and a whole lot of ties. Every once in a while, however, there are some unambiguous wins. They're not common - experiencing one once a month or means things are going pretty well. When they occur, however, they're fairly memorable. There's one moment from early in my clerkship experience that, while I can't talk about it publicly, even semi-anonymously on this blog, that I will never forget. When going through the roughest aspects of training, or of the job itself, these moments are soul-saving memories, a reminder that while most of what physicians do isn't all that consequential, sometimes can be exceedingly consequential. It's the best argument I have for pushing through all the muck in medicine.
Wednesday 18 January 2017
Obamacare and the Prospect of Repeal
As a Canadian medical student, it's worth keeping an eye on other healthcare systems. They can be a source of inspiration when advocating for changes to our own system, as well as a warning when other changes are being considered here that have not worked well elsewhere.
The US has a reasonably effective, but highly unequal and terribly inefficient healthcare system. This has been true for decades. It was true before Obamacare came in, it's been true since Obamacare was implemented, and it seems likely to be true in the near future as well. However, changes are on the horizon. US Republicans have made opposition to Obamacare to be a defining element of their party policy and they now have near-full authority to alter the American healthcare landscape as they collectively see fit.
In that light, I've become intrigued by this AskReddit thread I recently stumbled across, "US residents of Reddit: How will the repeal of the Affordable Care Act affect you...positively or negatively?". While hardly scientific, this kind of personal feedback offers a fairly unique glimpse into the effects of healthcare policy on individuals in real-time.
The answers seem to be falling into two categories, revealing both the strengths and weaknesses of Obamacare. On the beneficial side, there are numerous stories of individuals with significant, long-term medical conditions who would be medically or financially crippled without Obamacare. These individuals would be denied care or be forced to pay insurance costs effectively on par with their extensive medical costs if Obamacare didn't exist. In extreme cases, they would face bankruptcy or premature death due to these financial burdens.
On the other side is people, often younger individuals or families, facing insurance bills that eat up a substantial portion of their income and provide little benefit given their current health. The figures here are obscene in some cases, hundreds of dollars per month with high deductibles. Together, these conditions mean the insurance is useless for the day-to-day medical expenses of generally healthy individuals, functioning only as expensive disaster insurance in the case of an accident or unexpected illness.
These two outcomes are directly related. Obamacare's primary goal was to increase coverage, particularly for individuals with pre-existing conditions. These people have medical costs beyond what they can afford in insurance payments. To afford to cover them, premiums had to rise on other, healthier individuals. That's not very helpful for those healthier people, especially those without much money, as the cost of insurance goes up for them without any gain in benefits. So, some will choose to drop their health insurance, rightfully determining that the cost of maintaining their insurance is not worth their premiums. To prevent this logic from causing a spiral of higher costs and more people dropping out of the market, Obamacare mandated that everyone buy insurance. That means younger, healthier people buying health insurance more expensive than their needs to cover the costs of sicker, typically older individuals who pay less than their needs.
Virtually every country's healthcare system involves some form of these transfers, from the young and healthy to the older and sicker. It's effectively a requirement for a functioning healthcare system. The anecdotes from the AskReddit thread are therefore entirely unsurprising in general features - to move towards universal care, the proportion of medical costs covered by healthy individuals will almost certainly increase, in order to lower costs on sicker individuals.
However, there is a problem in scale and precision unique to the US. American healthcare is terribly inefficient, costing far more than comparable countries. The premiums quoted for healthy individuals in the AskReddit thread are beyond what they could be or would be in other systems. Likewise, the burden of covering the costs is falling disproportionally on lower-income individuals relative to other countries. To put this in perspective, under the American system, I would have to buy the same insurance this year that I'm in school, with no income, as I would next year with a solidly middle-class salary, and then again when I'm a practicing physician in a few years with an upper class income. By contrast, in Canada, my healthcare costs would vary significantly with my income via taxes. Obamacare put some subsidies in to help balance things out, but these have proved to be inadequate in many cases.
Obamacare was deeply flawed and the AskReddit thread exemplifies who those flaws have affected unfairly. Republicans are eager to fix this problem of overly high costs for relatively healthy individuals and it seems clear that this can be accomplished. Whether they will pursue policies that satisfy that goal, without causing additional, more serious problems as a result, remains to be seen.
The US has a reasonably effective, but highly unequal and terribly inefficient healthcare system. This has been true for decades. It was true before Obamacare came in, it's been true since Obamacare was implemented, and it seems likely to be true in the near future as well. However, changes are on the horizon. US Republicans have made opposition to Obamacare to be a defining element of their party policy and they now have near-full authority to alter the American healthcare landscape as they collectively see fit.
In that light, I've become intrigued by this AskReddit thread I recently stumbled across, "US residents of Reddit: How will the repeal of the Affordable Care Act affect you...positively or negatively?". While hardly scientific, this kind of personal feedback offers a fairly unique glimpse into the effects of healthcare policy on individuals in real-time.
The answers seem to be falling into two categories, revealing both the strengths and weaknesses of Obamacare. On the beneficial side, there are numerous stories of individuals with significant, long-term medical conditions who would be medically or financially crippled without Obamacare. These individuals would be denied care or be forced to pay insurance costs effectively on par with their extensive medical costs if Obamacare didn't exist. In extreme cases, they would face bankruptcy or premature death due to these financial burdens.
On the other side is people, often younger individuals or families, facing insurance bills that eat up a substantial portion of their income and provide little benefit given their current health. The figures here are obscene in some cases, hundreds of dollars per month with high deductibles. Together, these conditions mean the insurance is useless for the day-to-day medical expenses of generally healthy individuals, functioning only as expensive disaster insurance in the case of an accident or unexpected illness.
These two outcomes are directly related. Obamacare's primary goal was to increase coverage, particularly for individuals with pre-existing conditions. These people have medical costs beyond what they can afford in insurance payments. To afford to cover them, premiums had to rise on other, healthier individuals. That's not very helpful for those healthier people, especially those without much money, as the cost of insurance goes up for them without any gain in benefits. So, some will choose to drop their health insurance, rightfully determining that the cost of maintaining their insurance is not worth their premiums. To prevent this logic from causing a spiral of higher costs and more people dropping out of the market, Obamacare mandated that everyone buy insurance. That means younger, healthier people buying health insurance more expensive than their needs to cover the costs of sicker, typically older individuals who pay less than their needs.
Virtually every country's healthcare system involves some form of these transfers, from the young and healthy to the older and sicker. It's effectively a requirement for a functioning healthcare system. The anecdotes from the AskReddit thread are therefore entirely unsurprising in general features - to move towards universal care, the proportion of medical costs covered by healthy individuals will almost certainly increase, in order to lower costs on sicker individuals.
However, there is a problem in scale and precision unique to the US. American healthcare is terribly inefficient, costing far more than comparable countries. The premiums quoted for healthy individuals in the AskReddit thread are beyond what they could be or would be in other systems. Likewise, the burden of covering the costs is falling disproportionally on lower-income individuals relative to other countries. To put this in perspective, under the American system, I would have to buy the same insurance this year that I'm in school, with no income, as I would next year with a solidly middle-class salary, and then again when I'm a practicing physician in a few years with an upper class income. By contrast, in Canada, my healthcare costs would vary significantly with my income via taxes. Obamacare put some subsidies in to help balance things out, but these have proved to be inadequate in many cases.
Obamacare was deeply flawed and the AskReddit thread exemplifies who those flaws have affected unfairly. Republicans are eager to fix this problem of overly high costs for relatively healthy individuals and it seems clear that this can be accomplished. Whether they will pursue policies that satisfy that goal, without causing additional, more serious problems as a result, remains to be seen.
Sunday 15 January 2017
Predicting Specialty Competitiveness - 2017 Edition
Last year I tried to take a guess at the competitiveness of the larger specialties in Canada. I even went so far as to put numbers to my guesses. My accuracy was... not good. At least, it wasn't quantitatively good. It was a popular post nevertheless, so I suppose my random speculation has some minor value. This year, however, I'll be making my predictions a bit more qualitative, to spare myself the embarrassment of my quantitative imprecision!
I'll also avoid the specialty-by-specialty analysis. Unfortunately most specialties don't change much in a year, so when I started doing so, I just ended up repeating myself quite a bit. Instead, I'll lump specialties together by my expectations of changes in their competitiveness relative to the last couple years.
Increased Interest, Mild-to-Moderately Increased Competitiveness
In this category: Internal Medicine, Physical Medicine and Rehabilitation, Diagnostic Radiology, Radiation Oncology.
Diagnostic Radiology has had a few years of being relatively uncompetitive, but interest in the field appears to be back up a bit this year. Radiation Oncology has suffered with a terrible job market, but it seems to be improving somewhat, driving some interest back into this relatively well-paying, good lifestyle specialty. Internal Medicine saw a large jump in interest last year relative to its medium-term average and that seems to have been maintained this year, benefiting from decreased interest both in surgical specialties as well as Family Medicine. PM&R shockingly became one of the most competitive specialties last year and I do not expect that to change at all. Good lifestyle, alright pay, unique and interesting work makes it very attractive and so it was long regarded as a hidden gem of specialties. It's no longer hidden and so I expect a competitive match to PM&R this year, likely comparable to last year.
Similar Interest, Decreased Positions, Mildly Increased Competitiveness
In this category: Anesthesiology, OBGYN, most surgical specialties.
Pretty much every specialty involving being in the operating room is seeing a small reduction in residency spots this year, with Plastic Surgery (slight increase) and Urology (no change) being the exceptions. Overall interest in surgical specialties has been steadily declining over the past decade, but seems to be plateauing. In response to a weak job market, positions in these fields have been cut. The sum of this is that even with the new nadir of interest, overall competitiveness may, if anything, increase. Would-be surgeons, OBGYNs and anesthesiologists look to continue to have their work cut out for them to match.
Top-Tier of Competitiveness, Unlikely to Change
In this category: Dermatology, Plastic Surgery, Emergency Medicine.
These three specialties have solidified themselves as being uniquely competitive and that doesn't look to change much this year. ENT or Ophthalmology are competitive enough at baseline that in an odd year they might squeeze ahead of one of the three, but it'd be a temporary (and unexpected) blip for that to occur this year. PM&R also has an outside shot at being more competitive than these three given its huge increase in popularity last year, but I'm expecting these three to stay clustered at the top this cycle.
Similar Interest, Small Increase in Positions, Similar Competitiveness
In this category: Family Medicine, Psychiatry
When one specialty loses residency positions, another tends to gain them. Family Medicine and Psychiatry are those specialties, reflecting the higher demand for physicians in these fields. For Family Medicine, this comes on the heels of a successful decades-long push to get more medical students into family practice, combined with slowly increasing numbers of residency spots. Last year was the first year in a decade where interest in Family Medicine declined. Family Medicine has never been competitive by any metric, and I don't expect this year to be much different. Psychiatry, in contrast, has become a little more competitive in recent years and is no longer the near-guaranteed match it used to be. It's a unique field, however, and continues to have low pay despite a stellar job market. There's a limit to how much interest the field can generate for itself, so I would expect the additional positions to make Psychiatry a bit less competitive this year than last year.
For the most part, specialty competitiveness will stay roughly where it was last year. Large, dramatic swings in competitiveness tend to be statistical anomalies in smaller specialties. More often, changes in specialty competitiveness take place over the course of several years with slow, incremental adjustments, reflecting change job markets, working conditions, or pay, each of which change fairly slowly as well. I have not heard any word of any particular specialties being dramatically different from previous years beyond the normal year-to-year variations. I've been surprised in the past, however... we'll see how well it turns out this year!
I'll also avoid the specialty-by-specialty analysis. Unfortunately most specialties don't change much in a year, so when I started doing so, I just ended up repeating myself quite a bit. Instead, I'll lump specialties together by my expectations of changes in their competitiveness relative to the last couple years.
Increased Interest, Mild-to-Moderately Increased Competitiveness
In this category: Internal Medicine, Physical Medicine and Rehabilitation, Diagnostic Radiology, Radiation Oncology.
Diagnostic Radiology has had a few years of being relatively uncompetitive, but interest in the field appears to be back up a bit this year. Radiation Oncology has suffered with a terrible job market, but it seems to be improving somewhat, driving some interest back into this relatively well-paying, good lifestyle specialty. Internal Medicine saw a large jump in interest last year relative to its medium-term average and that seems to have been maintained this year, benefiting from decreased interest both in surgical specialties as well as Family Medicine. PM&R shockingly became one of the most competitive specialties last year and I do not expect that to change at all. Good lifestyle, alright pay, unique and interesting work makes it very attractive and so it was long regarded as a hidden gem of specialties. It's no longer hidden and so I expect a competitive match to PM&R this year, likely comparable to last year.
Similar Interest, Decreased Positions, Mildly Increased Competitiveness
In this category: Anesthesiology, OBGYN, most surgical specialties.
Pretty much every specialty involving being in the operating room is seeing a small reduction in residency spots this year, with Plastic Surgery (slight increase) and Urology (no change) being the exceptions. Overall interest in surgical specialties has been steadily declining over the past decade, but seems to be plateauing. In response to a weak job market, positions in these fields have been cut. The sum of this is that even with the new nadir of interest, overall competitiveness may, if anything, increase. Would-be surgeons, OBGYNs and anesthesiologists look to continue to have their work cut out for them to match.
Top-Tier of Competitiveness, Unlikely to Change
In this category: Dermatology, Plastic Surgery, Emergency Medicine.
These three specialties have solidified themselves as being uniquely competitive and that doesn't look to change much this year. ENT or Ophthalmology are competitive enough at baseline that in an odd year they might squeeze ahead of one of the three, but it'd be a temporary (and unexpected) blip for that to occur this year. PM&R also has an outside shot at being more competitive than these three given its huge increase in popularity last year, but I'm expecting these three to stay clustered at the top this cycle.
Similar Interest, Small Increase in Positions, Similar Competitiveness
In this category: Family Medicine, Psychiatry
When one specialty loses residency positions, another tends to gain them. Family Medicine and Psychiatry are those specialties, reflecting the higher demand for physicians in these fields. For Family Medicine, this comes on the heels of a successful decades-long push to get more medical students into family practice, combined with slowly increasing numbers of residency spots. Last year was the first year in a decade where interest in Family Medicine declined. Family Medicine has never been competitive by any metric, and I don't expect this year to be much different. Psychiatry, in contrast, has become a little more competitive in recent years and is no longer the near-guaranteed match it used to be. It's a unique field, however, and continues to have low pay despite a stellar job market. There's a limit to how much interest the field can generate for itself, so I would expect the additional positions to make Psychiatry a bit less competitive this year than last year.
For the most part, specialty competitiveness will stay roughly where it was last year. Large, dramatic swings in competitiveness tend to be statistical anomalies in smaller specialties. More often, changes in specialty competitiveness take place over the course of several years with slow, incremental adjustments, reflecting change job markets, working conditions, or pay, each of which change fairly slowly as well. I have not heard any word of any particular specialties being dramatically different from previous years beyond the normal year-to-year variations. I've been surprised in the past, however... we'll see how well it turns out this year!
Tuesday 10 January 2017
Last-Minute Decisions
With clinical electives done, my entire class is back in the school and catching up after a long period more or less off on our own. We're also all now finalized into our specialty choices. Some people are applying to multiple specialties with some degree of uncertainty, some are backing up, but there's no longer any room for being coy about specialty preferences - everyone's had to make a commitment one way or another.
So, we're finding out a lot about each other's final choices. After over 3 years with my classmates, it is interesting to see what people are ending up with. Most weren't huge surprises, with people either applying to what they had already expressed interest in or committing to one of the two or three options they were considering. There were a few last-minute surprises though, where a classmate did a hard switch to a completely unrelated specialty either near the end of 3rd year or even after doing some/all of their electives.
So, this post is mostly just a reminder for those still early on in medical school that while it's worth exploring specialties early as well as having a game plan for your clerkship and elective rotations, last-minute changes do happen, regularly.
So, we're finding out a lot about each other's final choices. After over 3 years with my classmates, it is interesting to see what people are ending up with. Most weren't huge surprises, with people either applying to what they had already expressed interest in or committing to one of the two or three options they were considering. There were a few last-minute surprises though, where a classmate did a hard switch to a completely unrelated specialty either near the end of 3rd year or even after doing some/all of their electives.
So, this post is mostly just a reminder for those still early on in medical school that while it's worth exploring specialties early as well as having a game plan for your clerkship and elective rotations, last-minute changes do happen, regularly.
Saturday 7 January 2017
Considering a Career in Medicine - Helping Others
We focus a lot on how students can prove they're good enough for medicine. These posts are for students wondering if medicine is good enough for them.
Short Version: A desire to help others is a critically important trait for an excellent physician to possess. However, a desire to help others provides little reason to go into medicine ahead of a plethora of other careers which also provide significant benefits to others. Physicians do provide assistance to their patients of course, but the effectiveness of that assistance is variable and often overestimated. Medicine is an inexact science and there will always be some patients who are harmed despite theoretically optimal management. Furthermore, even for physicians who make every effort to provide the best care for their patients, mistakes will be made and patients will suffer the consequences. Overall, physicians do improve the lives of those they serve and have the potential to be very impactful, yet need to maintain awareness of their limitations.
Long Version: I consider a desire to help others to be a near-necessity for a competent, compassionate physician. Many things can be and are taught in medical training, but empathy – and the passion to utilize it consistently – is not. Medicine therefore seems like a natural fit for caring, intelligent individuals who want to use their abilities to do some good in their communities or the world at large, with a career that reflects that focus on benefiting others first.
Yet, medicine is far from unique in being beneficial to others. Within healthcare, there is a multitude of careers which directly benefit patients in need in exceedingly meaningful ways. Physicians rarely, if ever, act alone in their administration of medicine, nor would they be effective acting independently of other professions within healthcare. Nurses, pharmacists, social workers, dentists, medical laboratory technologists, medical radiation technologists, audiologists, speech language therapists, physiotherapists, occupational therapists, EMTs... it goes on. Patients don't always need help from a physician and rarely need help from a physician only.
Additionally, non-healthcare workers can have a huge impact on people's health. Many of the gains seen in health over the past century are not attributable to advances in medicine or the delivery of healthcare. Increased wealth, better working conditions, improved nutrition, and cleaner environments have all played significant roles. Future gains (or holds) in human health are very likely to continue to involve those working in these fields, whether in the public, non-profit, or private sectors.
Of course, human needs extend beyond healthcare, and there are many ways to contribute to others' lives. Jobs in local charities, social development, education, and policing are often considered to be in the service of others. Careers not traditionally though of as being for the sake of others are nevertheless invaluable in our society, such as farming, construction, entertainment, or even (some) financial services. The perception that certain careers help people more than others is just that, a perception. Similar to the discussion on prestige, such perceptions are often unfounded and apply to the aggregate. An ethically-minded, competent banker can be of significant help to their clients. An unethical, incompetent physician can be an immense burden on their patients. The individual often matters more than the profession when it comes to the effect, positive or negative, on those around them.
Nevertheless, by improving health, physicians absolutely make a positive impact on their patients. Medical advances have undoubtedly extended life and improved its quality. Physicians, acting to implement those advances, are a critical part of maintaining if not furthering that positive change in the world. There have been times in my training already where the positive impact of medicine could not be denied. A man 10 years cancer-free and officially declared cured. A father, admitting that he was at his limit and taking the first step in getting help for long-standing depression. A mother getting to finally take her child home for the first time after months in hospital. These moments stick with you and many more interactions will occur where the benefit to the patient is not immediately obvious.
Yet at the end of the day, how much of an impact will a typical physician have? Likely a lot less than expected. While human health has improved, as noted above, much of that is due to societal advances outside of medicine. Likewise, much of the benefits of medical advances can be attributed to non-physicians. Where physicians can take responsibility for gains in health, those gains are often fairly limited. Most interactions with patients will not result in meaningful change to their health. Some patients require no intervention. Others require a test that does not end up changing management. Others will undergo indicated treatment that, by chance, produces no benefit. That last instance is far more common than the public often believe; if an intervention has been demonstrated in high-quality trials to help 1 in 10 people who receive that treatment - meaning 9 in 10 will receive no benefit - it has a higher rate of benefit, not to mention a stronger evidence base, than much of what is done in medicine.
Medical interventions also come with risks and harms. The phrase "do no harm", often associated with the Hippocratic Oath (though it does not appear in the original text), is notably absent from the modern version I took when I entered medical school. There's good reason for that as to be a physician necessarily means causing some harm. To provide optimal care is to accept risk, so some negative outcomes are inevitable. Expected benefits should always outweigh expected risks or harms, but the element of chance does not always turn out in our favour.
To go a step further, all the above applies to a physician providing optimal care. That is, one who is making no major mistakes or errors in judgment. No physician practices perfectly 100% of the time. With luck, most mistakes will be minor or lead to reversible harms, but bigger mistakes happen too, even to the best physicians.
I want to leave this post on a positive message, because physicians do have the potential to do significant good in the world and, importantly, the profession is strengthened by those with altruistic intentions. I do want future physicians to come in with a degree of realism, however, as too often the ideals of medical students run up against the realities of current practice and idealism gets replaced by cynicism. Likewise, on the other side of the spectrum, some physicians get through their training continuing to overestimate their impact and become conceded, failing to recognize the important contributions of non-physicians within and outside of healthcare. Aspiring physicians are not wrong to pursue medicine as a way to help others, but as with the previous post on money, medicine is not the indisputably best pathway towards helping others and as a result, alternative careers are worth contemplating.
Yet at the end of the day, how much of an impact will a typical physician have? Likely a lot less than expected. While human health has improved, as noted above, much of that is due to societal advances outside of medicine. Likewise, much of the benefits of medical advances can be attributed to non-physicians. Where physicians can take responsibility for gains in health, those gains are often fairly limited. Most interactions with patients will not result in meaningful change to their health. Some patients require no intervention. Others require a test that does not end up changing management. Others will undergo indicated treatment that, by chance, produces no benefit. That last instance is far more common than the public often believe; if an intervention has been demonstrated in high-quality trials to help 1 in 10 people who receive that treatment - meaning 9 in 10 will receive no benefit - it has a higher rate of benefit, not to mention a stronger evidence base, than much of what is done in medicine.
Medical interventions also come with risks and harms. The phrase "do no harm", often associated with the Hippocratic Oath (though it does not appear in the original text), is notably absent from the modern version I took when I entered medical school. There's good reason for that as to be a physician necessarily means causing some harm. To provide optimal care is to accept risk, so some negative outcomes are inevitable. Expected benefits should always outweigh expected risks or harms, but the element of chance does not always turn out in our favour.
To go a step further, all the above applies to a physician providing optimal care. That is, one who is making no major mistakes or errors in judgment. No physician practices perfectly 100% of the time. With luck, most mistakes will be minor or lead to reversible harms, but bigger mistakes happen too, even to the best physicians.
I want to leave this post on a positive message, because physicians do have the potential to do significant good in the world and, importantly, the profession is strengthened by those with altruistic intentions. I do want future physicians to come in with a degree of realism, however, as too often the ideals of medical students run up against the realities of current practice and idealism gets replaced by cynicism. Likewise, on the other side of the spectrum, some physicians get through their training continuing to overestimate their impact and become conceded, failing to recognize the important contributions of non-physicians within and outside of healthcare. Aspiring physicians are not wrong to pursue medicine as a way to help others, but as with the previous post on money, medicine is not the indisputably best pathway towards helping others and as a result, alternative careers are worth contemplating.
Tuesday 3 January 2017
Improvements
I wrote a while back about making some improvements in my life. Out of shape, not eating well, not sleeping well, not getting much exercise, stress at a fairly high level. Seeing as it's the new year, I think it's worth reflecting on those improvements.
I made a few changes in my habits in the hopes of improving that situation. Started running, monitored my eating habits, tried to focus on maintaining a more regular sleep schedule. It went well for a while, kept it up for a month or two. Lost the 10 lbs I put on during clerkship, was able to fit back into a few clothes that had gotten a bit too tight, and was generally feeling in better spirits overall.
Running unfortunately stopped with the cold weather. I'll need to find a way to keep up my exercise habits in colder weather, because unless global warming kicks it into high gear, I'm only going to be able to run outside for about half the year, at least using the gear I have. Eating habits kept up a bit longer, though I stopped keeping track of my calories after a month or so. The holidays are not the greatest for avoidance of sugar... I put on 5 lbs, pretty much entirely in the last 2-3 weeks, cutting my gains over the last 4 months in half. If nothing else, this is a great reminder about how hard weight loss. Persistence is necessary, but hard. Managed to successfully transition my morning glass of juice to tea though, so that's a win.
Continuing with the positives, my stress levels have definitely fallen, despite it being CaRMS time. Consistent sleep, even though I'm still lacking a little in the total amount, has helped. I've been a bit more social lately, something that fell off a cliff in clerkship and in medical school in general (though a series of restaurant dinners haven't exactly helped the waistline either). I've also started prioritizing some things I enjoy, like watching the hockey game or doing some reading. I've had some luck in cutting down on screen time as well - getting a subscription to a weekly newspaper has helped a lot, letting me get a bit of a different perspective and taking some of my online reading offline.
So, what are the next steps? First is getting back to exercise and eating well. I did it before, it worked, I can do it again. Getting back to good sleep habits in the next step - in general, I've had good sleep hygiene, just not starting the process early enough. That can change. Lastly, in continuation with general stress reduction strategies, I'm cleaning out my apartment. That's been an on-going holiday project. I have a large amount of minimally functional space, as well as many possessions that I'm not using and will likely never use. Getting organized has been cathartic in a way.
Anyway, this post is mostly just a reminder that in medicine, no one will look out for your well being unless you make it your own priority. I've enjoyed the last couple months, despite the hiccups and mixed results. Having the luxury of call-free electives hasn't hurt, and going into the remainder of fourth year, where I'm back in the classroom with ample free time, should give plenty of opportunity to continue good habits. The next challenge will be to solidify these habits and make them adaptable to the busy schedule of residency - when wellness will matter all that much more!
I made a few changes in my habits in the hopes of improving that situation. Started running, monitored my eating habits, tried to focus on maintaining a more regular sleep schedule. It went well for a while, kept it up for a month or two. Lost the 10 lbs I put on during clerkship, was able to fit back into a few clothes that had gotten a bit too tight, and was generally feeling in better spirits overall.
Running unfortunately stopped with the cold weather. I'll need to find a way to keep up my exercise habits in colder weather, because unless global warming kicks it into high gear, I'm only going to be able to run outside for about half the year, at least using the gear I have. Eating habits kept up a bit longer, though I stopped keeping track of my calories after a month or so. The holidays are not the greatest for avoidance of sugar... I put on 5 lbs, pretty much entirely in the last 2-3 weeks, cutting my gains over the last 4 months in half. If nothing else, this is a great reminder about how hard weight loss. Persistence is necessary, but hard. Managed to successfully transition my morning glass of juice to tea though, so that's a win.
Continuing with the positives, my stress levels have definitely fallen, despite it being CaRMS time. Consistent sleep, even though I'm still lacking a little in the total amount, has helped. I've been a bit more social lately, something that fell off a cliff in clerkship and in medical school in general (though a series of restaurant dinners haven't exactly helped the waistline either). I've also started prioritizing some things I enjoy, like watching the hockey game or doing some reading. I've had some luck in cutting down on screen time as well - getting a subscription to a weekly newspaper has helped a lot, letting me get a bit of a different perspective and taking some of my online reading offline.
So, what are the next steps? First is getting back to exercise and eating well. I did it before, it worked, I can do it again. Getting back to good sleep habits in the next step - in general, I've had good sleep hygiene, just not starting the process early enough. That can change. Lastly, in continuation with general stress reduction strategies, I'm cleaning out my apartment. That's been an on-going holiday project. I have a large amount of minimally functional space, as well as many possessions that I'm not using and will likely never use. Getting organized has been cathartic in a way.
Anyway, this post is mostly just a reminder that in medicine, no one will look out for your well being unless you make it your own priority. I've enjoyed the last couple months, despite the hiccups and mixed results. Having the luxury of call-free electives hasn't hurt, and going into the remainder of fourth year, where I'm back in the classroom with ample free time, should give plenty of opportunity to continue good habits. The next challenge will be to solidify these habits and make them adaptable to the busy schedule of residency - when wellness will matter all that much more!
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