Medicine, The All-Consuming

Left unchecked, medicine can easily dominate all aspect of life. This hits people at all stages of training and experience in medicine, but now that I've dipped my toe into residency, I think it likely hits residents the hardest. Residency means being both a learner and an employed junior physician, which has the unfortunate consequence of piling on both the open-ended responsibilities of a medical student to learn as much as possible, along with many (though not all) of the day-to-day responsibilities of an independent physician. Add on a situation of minimal control over one's own schedule and the need to continue to fight for a job on graduation, whether a fellowship or full employment, and medicine can easily take up every minute of the day, and every thought running through the brain.

For a small number of exceedingly passionate residents, this is exactly what they signed up for. Most residents, however, have parts of their life outside of medicine they would like to maintain or even prioritize, and that can become difficult in the metaphorical tempest of residency. Particularly when ambitions come into play, where a desired career path cannot be secured by simply showing up and performing well, medicine can push out those other, valued parts of life.

I'm finding myself falling into that trap early on in residency. I'm incredibly fortunate to be in a program with lower overall hours than many, and call schedules which are generally quite favourable. Yet this still means weeks far longer than a typical work week and the added time has largely gone towards maintaining a real sleep schedule and keeping up a rather bare-bones home life. My spare time now is still largely focused around medicine, either doing things for my career or, out of anxiety of having to do them all the time, unproductively procrastinating those activities.

As I was fairly ambitious in medical school, I've essentially been running on this medicine-focused treadmill for about 3 years straight now. I've learned this doesn't work well for my health, well-being, or even my achievement levels. I was able to scale-down my commitments later into my third year of medical school and into my fourth year. My choice to go into Family Medicine was influenced by this realization, a choice I'm quite happy with thus far if only for the sake of my own health.

Yet I'm still struggling with balancing my ambitions within medicine with my ambitions outside of my career. I want to do more as a physician, as I see so many opportunities to do a better job for patients. However, I've learned from experience that you can give everything you have to the medical system and end up causing more harm - especially to yourself and your loved ones - than you see in benefits for patients.

Prioritizing medicine above the rest of life didn't work and, in retrospect, many more senior physicians told me as much. So, I've tried to play a balancing act in the past year and a half, weighing any benefits to being more active in medicine with drawbacks to life outside of medicine. Again, for my health this has been a positive change, yet it comes with one major drawback - my life is still dominated by my medical career. Even if I choose not to pursue a new opportunity within residency, or put in an additional hour in a clinical setting, or do an extra bit of studying, I'm still making that decision with medicine as the focus. Unfortunately, this is leading to a fair bit of resentment towards my own medical career, without a countervailing positive in my non-medical life.

Therefore, I'm going to try to change tacks once again. Beyond trying to maintain a balancing act, I'm going to see how things work when life comes first. Before lifting an extra finger for the sake of a medical career that seems rather indifferent to my efforts, I'm going to try to make sure I have time for the non-medical things in life I care about. Getting a real amount of exercise. Spending quality time with my spouse. Watching the hockey game. Reading the newspaper. And if I'm really lucky, pursuing some hobbies I've had on the back-burner for years. Only then will I do the non-essential work in my medical career. My hope is that I can attack those activities in medicine with the vigor they deserve and which, over the course of the past 3 years, has waned from exhaustion and over-exposure.

Part of that is this, my Medical Blarg. This blog started as my way of actively de-stressing about being a medical student. As it unexpectedly gained viewership, it felt like the one activity in medicine that was leading to something productive. The encouragement to keep going from posters was immensely appreciated. Yet, it's hard for me to deny that as a result of its viewership, this blog has, in a way, also become a part of my medical career. There reached a time when posting felt more like an obligation that the enjoyable exercise it started out as. As a result, I've pulled back a bit on my posting frequency. My hope is that doing so allows me to continue to blog, but with a bit more enthusiasm and genuineness that I have been able to in the past few months.

Residency, Block One

Well, I just finished up my first block of residency. Starting on my home rotation of Family Medicine, I got a chance to dive right into what I hope to be doing for the rest of my career. It's been a very busy transition (hence the complete lack of posting), but in a mostly good way. Here are my first impressions.

1) Increased Responsibility

This hit harder than I expected, and faster. I see my own patients. I review most of them with my preceptor, but not all of them. My preceptor sees my patients usually only when I ask them to. I can write my own prescriptions now - I even have a stamp with my name on it for those! It's a wonderful freedom in many respects, as I don't have to couch every single encounter based on what I think my preceptor wants. Instead, I can give my own impression and hedge only when I'm uncertain about the best answer.

Yet, that means when I mess up, it's all on me. And I've definitely messed up. No big screw-ups - life-or-limb cases are fortunately not that common in Family Medicine and I know enough to at least confirm my thoughts with my preceptor in these cases - but certainly less-than-optimal actions that could have been handled better. I recognize that's part of the learning process and that in my first rotation is very much expected, but it still hits a bit harder now than it did in medical school. As a student, if a patient's treatment was sub-optimal because of my mistake, outside of a clearly negligent decision, much of the fault would lie with the educational system that either failed to properly train or supervise my actions. Now those factors still matter, as I'm still a trainee, but as an employee, I share far more in that responsibility.

2) Rush, Rush, Rush

When I started my rotation, I got a slow introduction. Lots of time for patient appointments. Arguably too much time. I was getting bored going into my second week, and started asking to see more patients. Then I got ramped up to a full schedule in my third week. It. Was. Crazy. I managed to keep up with my schedule, yet only at the expense of my note-writing. On the busier days, I was at the clinic hours afterwards finishing my notes and completing other paperwork.

Nevertheless, I mostly kept my head above water and I'm fairly proud of that fact. At the end of my block, I was handling a workload roughly what I can expect as an early PGY-2 and while I wasn't nearly as consistent or efficient as the PGY-2's in the office (who were nothing short of amazing), I at least did the job. As I gain some more experience and familiarity, I'm hoping the late nights of note-writing well decrease.

That said, even my current "full schedule" pace is about half what it will be in full practice. Even with the advantages of a shorter lunch (currently I get over an hour, which I don't really need), lighter note requirements (my notes are detailed now, especially compared to the 2-3 lines most of my preceptors write), an extra exam room (I get a single room now), and no delays caused by checking with a preceptor, I'm nowhere near being able to operate at full speed. Yet, I've got 25 more blocks, including many family medicine blocks, to get up to that pace, so there's still plenty of time.

3) Home Call is Not Like In-House Call

One of the interesting quirks to my residency program is that we do a full home call on our Family Medicine blocks. It's not particularly frequent (about one weeknight every 2 weeks and one weekend every 2 months) and in many Family Medicine centres, it wouldn't be too busy. Except at my centre. Our weekend call is Friday night through until Monday morning. I got at least two dozen calls during that time, some of which were simple and straight-forward, others which took a fair bit of time to sort out. Ended up having to do a fair bit of driving, either to see patients in clinic over the weekend or to visit patients in the nursing home we cover.

The main advantage of home call is that you can still do life-stuff when you're not actively working. That's pretty great, since you can get a lot done if you don't get called often. It's way better than in-house call in that respect, where you're basically working a 24-hr shift that may involve some long breaks if you're lucky, but which doesn't allow you to do anything outside of the hospital. Yet, since my home call was over 60 hours long and was reasonably busy - during the day, I rarely got more than an hour off - I didn't get much opportunity to get anything done and developed some rather intense pager anxiety. It's surprisingly hard to "switch off" on the third day of being page-able at any time!

4) Conclusions

Overall, I'm enjoying residency more than I did medical school. There's a bit more independence and some clear ways to progress forward over time. Getting paid rather than paying insane amounts of tuition is a significant benefit, as finances are now slowly moving in the right direction. Month-long blocks rather than two week rotations provides a bit of stability, and the ability to take vacations provides some much-needed flexibility, though the schedule remains fairly hectic.

Life still isn't yet where I'd like it to be - I spend too much time at work or on work and don't have enough consistency or control over my own schedule to prioritize other aspects of living. I'll be glad to finally finish up in two years' time and to experience the supposed wonder of full, independent practice. Nevertheless, residency feels closer to my ultimate lifestyle goals than medical school did and what sacrifices are necessary feel more like they're in the service of meaningful progress than they did as a medical student.

Finances in Medicine - Big Life Expenses

As I move from student life to resident life, non-career life goals start to loom a little bit larger. At my age, many of my friends and colleagues are looking towards a few big expenses - getting a car, getting married, having kids, buying a house. None of these come cheap.

Car
This one's simple - most residencies require access to a vehicle, and in most cases, it's going to have to be your own vehicle. Buy something that fits your needs through residency that's reasonably low-maintenance (there's no time to be babying a fixer-upper). It shouldn't be a luxury vehicle. It'll likely be paid for through debt entirely and that's alright. It's a necessary business expense.

House
Ahh, the eternal debate - buy a house in residency or rent a place. In all honesty, there's no simple answer here, it'll depend on numerous factors. To the extent that there is any general advice, it's that the standard for Family Medicine residents is to rent, while the standard for those in 5-year specialties is to buy, but there are many exceptions to those guidelines.

The main reason to buy a house is to build equity with the money you're putting towards your living costs, thereby recouping some of that money rather than losing it as an expense outright. Buying a house becomes a forced investment - and a fairly good one at that - as the money paid towards a mortgage partially goes towards the house that you own, a house which is worth a lot of money and which will generally increase in price over time.

The main reason to rent is to avoid the costs and risks of homeownership. Spending money on rent is money that you'll never get back, but buying a house comes with its own expenses that will not be recouped. Maintenance, repairs, property taxes, interest (on the mortgage and, for residents, often on the down payment as well), closing costs, condo fees (if applicable) - all this adds up and is something renters don't need to deal with. Time is also a factor, as renting means that any housing issues that come up are the landlord's responsibility to deal with. Renting is also less risky, as houses can decline in value (but usually don't), and is more flexible if a move becomes necessary, as it often is for graduating residents.

All things considered, buying a house is usually a better financial decision in the long run. However, in the short-to-medium term, it comes with some distinct disadvantages. For those who have a little bit more medium term stability and a tolerance for some financial risk, it can be worthwhile. For those who face a bit more volatility in their upcoming housing needs or who are risk-averse, renting might be the better option and likely a bit cheaper in the short term. Regardless of the path chosen, all physicians will be able to afford a very nice property, likely a "forever home", only a few years after finishing residency - if not sooner.

Wedding
While everyone in residency needs transportation and housing, not everyone needs or wants to get married. Many do though, and the end of medical school is a prime time for it to happen. A good portion of my classmates just got married or have their wedding planned in the near future. Weddings, however, are expensive. Really expensive. Anything with a reception is likely to run at least $15k. More typical weddings are more in the $20-30k range. It's not hard to go above that upper end figure either. Oftentimes, these costs get offset by gifts from guests, either directly through money or through other gifts. Depending on the culture and attitudes of the guests, the entire cost of the wedding might be covered, but it's not something to count on either. For those uninterested in the traditional reception, a ceremony-only event is an option - whether it's the basic City Hall ceremony or a ceremony with more bells and whistles. The main cost of a wedding is the reception, and a very elegant ceremony can be funded for a fraction of the price of that reception.

Weddings are often financed by a combination of gifts, parental support, and debt. Fortunately, as a one-off event, most graduating medical students can afford that bit of extra debt without much difficulty. Still, when budgeting for the future, the expense of getting married should be in those calculations, because it is not a small one.

Children

As with weddings, many people are opting not to have children, so this may be a non-issue for a growing number of physicians. For those that want kids, children require some serious financial planning. The cost of raising a child to adulthood averages over $250k in Canada, with expenses being higher in the early years. For physicians with generally high standards of living and above-average expectations for their children's care, that figure is likely an underestimate. That's a significant and continuous cost to bear.

Perhaps most challenging for those in medicine, children can't always be put off until later, while houses and weddings can be delayed indefinitely. The biological clock is an unavoidable fact of life for a career path that requires training into many physicians' early 30's or beyond. Women in medicine unquestionably bear the brunt of this reality more so than men, though men are not exempt from timelines either when it comes to having children. Timing therefore becomes a rather important decision. The longer physicians wait to have children, the more financially secure they'll be, but the older they'll be before trying to conceive or adopt.

A small number choose to have children in medical school. Time-wise, this can be a good option. Outside of clerkship, schedules are much lighter and more flexible than they are in residency. Medical schools often do allow time off for children, though this typical means being kept back a year and may mean an extra year of tuition payments. Medical students are, naturally, quite young as well. Money is an issue though, as medical students are piling on debt, not bringing in an income. Within reason, debt-financing child expenses can be done. However, other expenses will have to be kept under tight control unless a high-earning partner is in the picture, and careful financial management is a must.

Waiting until becoming an attending physician is a more common time frame to start having children. By this point demands on physician time have (usually) settled down and are much more flexible. There should be plenty of financial resources available by this point as well. The downsides are age and the hassle of practice management. Age is fairly self-explanatory when it comes to waiting until after residency, but practice management is an often-neglected factor. Unlike in medical school and residency, attending physicians are now fully responsible for their own careers. Taking time off to have a child means, in many cases, having to find someone to cover your practice. This can be particularly worrisome immediately post-residency, when a physician is still working to establish themselves and may not be able to easily take time off just yet. These immediate post-residency career demands can push the timeline to have children back even further than intended. Still, for those who are on the younger side, in shorter residency programs, or happy with being on the older side to start trying, waiting until after residency can be a rather sensible choice.

At the end of the day, residency remains a very popular time to start having children. Time is in exceedingly short supply, but taking maternity or paternity leave is relatively straight-forward. Residents aren't exactly overflowing with money, but they've got enough coming in to support a household. They're older than medical students, but younger than attendings, most being in their late-20's or early-30's, which is a fairly favourable time to start having kids. Residency remains the standard "recommended" time to have children for these reasons.

Nevertheless, circumstances will be different for every individual physician, and there are certainly merits to starting to have children either before or after residency. The timing of having children is a balancing act of competing priorities, and any decision will involve some trade-offs. Proper financial planning and lifestyle management remain the greatest assets when considering children.

Finances in Medicine

Reaching the end of my final year of medical school, suddenly money has become very important. My student debt levels are reaching their maximum, but I'm about to start earning a real salary for the first time since I left my previous career to start medical school four years ago. With that comes a chance to move on to the next stages in life, as well as an obligation to start contributing financially to society at large, after having largely been a sponge for my life up until now.

Education on medical trainee finances, despite being rather unique and complex, is still largely lacking, and mostly coming from people who have a financial stake it your decisions. Most advisers are reasonably honest and up-front about the rationale behind their recommendations - true shysters get driven out of the industry fairly quickly - but sorting out what's best for you isn't always easy. Here's what I've found out so far.

Debt Management

Naturally, this starts in or even before the first year of medical school, when debt starts to build. Just a quick reminder of the basics, the ideal approach is to maximize scholarships/bursaries/grants first (free money!), then maximize government loans (usually come with no interest while studying, many have grants attached), then rely on private loans in the form of a line of credit (LOC) specific to medical students. Once residency comes and government loans start generating interest, usually at a higher rate than LOCs, it's best to roll the entire sum of the government loans into the LOC, unless you qualify for certain governmental debt-relief programs that require you to leave a balance in those government loans to take advantage of them. There are some individuals who, through bursaries or other outside funding, can get through medical school with just government loans.

Some money can be earned by working in medical school by working. Since government loans and grants get reduced by personal income, however, there are significant diminishing returns on getting a job. Some jobs - such as research positions - can be worthwhile even if they were paid nothing, and so earning money from them is just a small extra benefit. Jobs that are taken just for the money may not be worthwhile, however, as it's not hard to be in a position where a student is working for far less than minimum wage once lost governmental grants are taken into account.

Once in residency and earning a real salary, debt can start to be paid down, though it does not have to be. Depending on personal circumstances, some people will build on their debt, some will keep it stable by paying off any generated interest, others will reduce their debt significantly. For the most part, however, now is when debt-paying habits can start in earnest, even if it is just covering the interest. Automatic transfers are ideal, since it's very easy to upgrade lifestyle to match income if that money is perceived to be available. Developing these habits now is mostly important to carry on into post-residency life, as debt-repayment strategies are pretty much identical to the basic savings strategies which define whether a physician is financially secure or has constant money troubles.

Throughout medical school and into residency, the best thing a trainee can do for their debt is to keep it low by controlling spending. Living a modest lifestyle, even when you can technically afford more, makes future financial decisions significantly easier. Living in a smaller place, eating out less, forgoing nice but unnecessary luxuries, and ultimately, budgeting to keep costs low is how to succeed financially. As with debt repayment, forming the habit that spending is to be deliberate and well below one's means is the most critical aspect. Many physicians have financial troubles and for 99% of them, it's a problem of uncontrolled spending. Learning how to avoid those problems early on, in medical school and residency when it still has a large impact on overall debt load, is an important skill.

There's a lot more financial stuff on my mind these days, but this post started getting a little out of hand, so I'll split it into parts. Best advice I can give to those looking to revamp their finances is to get informed and tailor their approach to their own situation. There's some good advice there, but rarely a one-size-fits-all approach. Money management is not something that can be outsourced, medical students, residents, and physicians need to take an active and informed role in their own finances.

Addiction and Physicians - Why Having an MD Doesn't Make You Special

Haven't posted much lately, though not necessarily by intention. Life's been very crazy lately, but in a very good way.

Wanted to touch on a story that's rightfully making the rounds on social media, of a Canadian physician talking about his addiction to Fentanyl. Fentanyl is the new addict drug of choice in much of Canada, particularly in southern Ontario. It's been building for a few years. Every conversation I have with those in addictions or drug enforcement says that this is where we're seeing a big focus. It's a very powerful narcotic, one that's definitely overprescribed, and it has numerous routes of absorption. In many ways, it's the most recent culmination of the wider opioid crisis that's been growing for decades now.

Dr Gebien's tale is worth reading for its account of the devastating effects of opioid addiction, and the hubris of physicians who think they're immune to such common human failings. On the former point, there's enough written by more knowledgeable people than me that I won't say much besides a reiteration that I want my practice to be very opioid-averse. As far as I'm concerned, unless something's going to cure your pain very soon (usually by an operation of some sort), or we expect you to die at some point in the near future, I have trouble seeing the role of opioids. They don't work well long term, they're addictive, and they come with tons of side-effects. They're not really a treatment for pain, they're a way to stall it in the short-term.

On the second point, it can't be emphasized enough - doctors are human and we fall victim to all the things humans fall victim to, including addiction. One particular point to mention about this story is the hazards of self-prescribing. Physicians are not supposed to treat anyone who isn't their patient, including themselves. That means no treating family or friends except in very unique circumstances. That means no treating co-workers. That means no treating fellow physicians unless they're in your office for a valid reason. I can't say how often I've seen a physician write off a prescription to one of their colleagues based on that colleague's word alone. No history. No physical. No investigations. Just "I need this script, can you help me out?", and bam, done. In one instance, a physician asked a colleague for a medication for their child, effectively treating their own kid with the help of a fellow physician who never even laid eyes on that child! Don't do this. Yes, it sucks to have to go to your GP to get a simple script. Yes, you know exactly what needs to be done. You know who else it sucks for to have to do that? EVERYONE! Being a physician should not get you a fast track to basic medical care, nor should it allow you to skip the basic components of treatment, such as a proper evaluation. Please, colleagues, supervisors, and anyone coming afterwards, just don't do this, and don't help others do this. It's unethical and can lead to some very dark outcomes.

There's a few other elements to this story that deserve a quick mention, since they probably contributed to his situation and are much more common traps for physicians to fall into then addiction. First is proper money management. He was making $300k a year and needed parental assistance to cover two rehab-related bills of $10k and $80k, in addition to needing to put $35k on a line-of-credit. Everyone, regardless of profession, should have an Emergency fund of at least 6 months of living expenses, ideally 1 year's worth. In his case, it doesn't sound like he had anywhere close to that. I don't doubt that a fair bit of money was going to feed or hide is addiction. Yet, there are other clear missteps. Buying a large house, luxury cars, and a boat weren't necessary and probably weren't affordable. Even if your means are great, you still need to live within them.

Secondly, this story highlights the need for a robust support system. Here we see only one side of the story, so it's hard to draw conclusions, but I don't get the sense of a reliable base of support from Dr Gebien's wife or parents. Their relationships seem dysfunctional and his mother, who looked to be dealing with her own problems of opioid use, was an enabler in his addiction. Building connections with reliable people before, during, and after medical training is important. Equally important is picking the right partner - they're the one family member you get to choose.

Overall, Dr Gebien's story serves as an excellent case study in the hazards of being a physician, and the failings too many of us assume we'll avoid just by having an MD after our names. He doesn't come across well in telling his own story, and there are numerous areas to find fault in beyond just his addiction. Yet, that makes his story all the more valuable to share. Being a doctor doesn't make anyone special, better, or more capable at handling the challenges of life. When physicians start to think that it does, they start engaging in behaviours that are destructive to their own lives or, as Dr Gebien's story briefly mentions, the lives of loved ones and colleagues. Staying grounded, staying humble, and remaining self-critical of our own behaviours is critical for physicians.

Pets and Private Health Care

About a week ago, my dog had an unfortunately run-in with another dog - who we know and is usually friendly - that resulted in him getting nipped pretty hard in his side. Wasn't too bad, but deep enough that it couldn't be left to heal on its own, particularly as the other dog had been carrying around a dead carcass of something or other in its mouth just prior (hence the nip, as my dog got interested and the other dog got defensive about their new prize).

It was late at night when we noticed the injury, so we took him to the emergency veterinary clinic to avoid letting him sit with it overnight. We were hoping for a quick clean-out and stitch, but because our dog is giant, easily frightened, and we couldn't rule out a bad contamination from the bite, the vet quite reasonably want to explore the wound under light sedation. We were given a quote before going ahead with anything and the final bill lined up with that quote perfectly, about $500.

In short, it was professional, competent care with excellent price transparency.

And yet, I'm in a very fortunate position to be able to afford that $500 of care. Many people couldn't, especially for a pet. If I was in a worse economic situation, I could have had to gamble that my dog would heal on his own. With his small wound, he would likely have done just fine, but it would still involve an element of risk for his well-being.

Why do I bring this up? Well, because private healthcare is back in the mix in Canada.

Now, "private healthcare" is about as vague a term as you can get. Canadian health services are largely provided by private organizations, just funded from mostly public sources. Yet most people wouldn't call Canadian healthcare private. Likewise, when discussing current efforts to allow private billing of provincially-insured healthcare services, there are a multitude of schemes that could be considered. Furthermore, when the Canadian healthcare system gets compared to other countries' systems with private components, it often gets forgotten that those countries actually have more government funding as a proportion of medical expenses than Canada does.

Therefore, when I speak of the encroachment of private healthcare in Canada, it's hard to do so without oversimplifying the debate, and I want to acknowledge that before going any further on this point.

Currently, there are more than a few physician groups and individual physicians expressing support for allowing private billing for otherwise publicly-covered healthcare services. In some cases, physicians have already opened such clinics and are operating them with questionable legality. One BC lawsuit is currently underway concerning such a clinic, this one focused on outpatient surgeries. In my experience thus far, a desire for a private option, or at least a belief that it is necessary, helpful, or inevitable, is a popular opinion among physicians. The notion is that private care could cover something lacking in our current public system, even if it's as simple as providing additional capacity for elective procedures.

My objection is that no matter the formulation, unless we dramatically reshape the public system as well, private care will provide some services of consequence to outcomes to some who can pay, but not to others who cannot. The only alternative is if private care adds no value whatsoever, in which case, what's the point? I felt enough worry about having to cover the costs for care of my dog with a condition that was relatively safe, with expenses I could afford, and when everything about his care went perfectly. To have to make that decision with a higher cost, a more serious condition, and the real possibility of sub-optimal outcomes would be so much worse. To make that decision for a human - myself or another loved one - would be even more difficult, as much as I love my dog. I also never want to be on the other side of this situation, having to ask patients to choose between their physical and financial health. For pets and other animals, these sorts of decisions are unavoidable - I don't think we'll ever have universal veterinary care. Yet, we can avoid these decisions for people, if we maintain and strengthen the public system we have now.

For the record, my dog is now fine. His wound is healing well with no signs of infection. He was a little anxious for the first day or two and is pretty upset that he has to wear a cone, but he's more or less back to his old, affectionate self!

Research and Other Extra-Curriculars

My medical school experience has been characterized by a decent amount of research and a LOT of extra-curriculars. Medical students in general are fairly active people, usually very eager to take on that one extra task, though at some point towards the end of second year or beginning of third year, I realized I had taken on just a little too much. Too many projects on the go and in the rush of clerkship, nowhere near enough time to do them all well.

So, about half-way through clerkship, I started pulling back. I left a few minor projects to fall by the wayside, delayed a few others or worked on them slowly, and wrapped up the ones I could. This helped me get through clerkship without losing my mind to stress, and I still managed to come away with what I think is a reasonable list of accomplishments through my previous 3+ years.

Yet, on one of my electives, I had a preceptor who embodied the concept of going above and beyond as a complete physician. Involved in both social and academic endeavours, he seem as enthralled by the non-clinical aspects of his work as he was by his clinical duties. You could tell that his enthusiasm for one area helped maintain his enthusiasm overall, in addition to keeping him at the forefront of knowledge. Granted, I had some reservations about some of his ideas, as his eagerness for their benefit didn't always match available evidence in my mind, but I can't help but admire that enduring passion.

Now that I'm back in class, with a lighter schedule and ample time to pursue some outside interests, it's been very tempting to stick with a low workload in terms of extra-curriculars. Yet, I pursued those extra-curriculars in the first place because I enjoyed them, because they made medicine itself more fulfilling and meaningful. My elective preceptor seemed to be of the same mindset, that the variety and diversity of projects - even though challenging - helped make medicine enjoyable. So, I've jumped back into a few. Just a few, and mostly at arms' length. I don't have the time to get much deeper into things, with (hopefully) only a few months left in my training. It's a nice balance at the moment.

Residency will put that balancing act to the test. For personal and professional reasons, I would like to be a bit more involved in non-clinical aspects than I was in clerkship. I'm counting on the fact that I'll be more familiar with the whole system and will generally have more stability in my rotations to help facilitate that, but weighed against the added responsibilities and pressures of residency, I'm likely being overly optimistic. Nevertheless, I think having a foot in the different aspects relevant to medicine is worthwhile.

While I do believe medicine should focus on a small set of core competencies, without the implication that physicians should be anything and everything, the advantage of being a true professional is the ability to branch out to satisfy interests and community needs. My elective time with this particular preceptor was a good reminder that this diversity was a major driver for me to enter medicine in the first place.

Rank Order List Submitted

Ok. It's final. My Rank Order List is now submitted and I don't intend to change it, even though the deadline is still 2 weeks away. Plenty of last-minute deliberations went into the list to the point that I'm honestly a bit surprised with some of the end result. My top 3 are the same top 3 I've had for a long time, but they're now in an order I had never considered prior to my interviews. Of the remaining 10 (I ranked 13 programs total, you know, for luck), there are also some surprises, including a program I almost didn't apply to at all sitting fairly close to the top of my ROL. Some that I thought would be higher fell down pretty low.

Interviews are as much tryouts for programs as they are for students. Some programs definitely impressive, proving more attractive than they looked at first glance. Others were quite underwhelming. I changed my rankings accordingly.

In any case, now I get to play the waiting game. I have exactly 1 month before I find out my match results. There's nothing more I can do to improve my chances, nor any new information I could find to change my preferences. Time for some Netflix binging, I guess!

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.

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.

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!

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.

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!

Considering Medicine - Prestige

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: Medicine a well-regarded profession. Most people generally assume physicians are reasonably intelligent and high-achieving. Perceptions of the profession are slowly changing, however, and not necessarily for the better. More importantly, prestige essentially represents the opinions of others based on superficial qualities and only matter to the extent that those opinions are valued. Prestige in a career is often most meaningful to those who feel their job lacks prestige. As such, its main value is in assuaging personal insecurities, but it can only do so much on that front. Having a prestigious profession is no substitute for developing strong personal self-esteem.  At the end of the day, prestige is a hollow comfort if a physician does not find the actual work of their job satisfying.

Long Version: Humans are social beings. We intrinsically care about what others think of us, even when those opinions fail to represent reality. It is in this light that we should consider the prestige of going into medicine.

The majority of individuals have positive opinions about physicians. In multiple polls, medicine is still regarded as one of the more respected, ethical, and trustworthy professions. Physicians tend to be thought of as intelligent and hard-working. Becoming a physician is often thought of as an achievement in isolation. Being a physician has many of the trappings of prestige, of being though of positively by society - with the "Dr." title, high pay, often an office, many times physicians get additional awards, or honours, or academic appointments.

It is hard to deny that medicine is a prestigious profession. Yet their are some cracks in public perception of physicians. With high earnings, physicians' earnings are coming into question, with concerns about the value the profession places on money. As medical knowledge disseminates more broadly, the expertise of physicians is more frequently under scrutiny by patients. Moreover, physicians can be seen as cold or uncaring when failing to meet the typically high expectations of empathy. If physicians ever were implicitly trusted because of their profession alone, that time has long passed.

What often gets lost in conversations about professional prestige is that while professions may have general qualities, they're made up of individuals. Individuals have their own qualities which may adhere to or contrast with those of their profession. For example, a physician isn't intelligent because they're a physician - they're intelligent because what they have acquired a good base of knowledge and the problem-solving skills necessary to use that knowledge effectively. The vast majority of physicians are intelligent, having the mental faculties to make complex clinical decisions competently, but there are exceptions. Becoming a physician doesn't instill intelligence automatically and as a result, a small minority of physicians are not particularly bright. Likewise, choosing to not become a physician will not remove intellect from an already-intelligent person.

So why should prestige matter at all? Well, it gets back to that original question - we care what others think of us. Furthermore, we want those positive opinions of us even when we don't have the time or opportunity to demonstrate our true qualities. It's not feasible or socially acceptable to demonstrate your level of intelligence to every person we meet. Our careers provide a proxy for who we are as people, whether we think that proxy reflects who we are or not. Being a physician provides a benefit of the doubt other professions often don't.

That benefit of the doubt can be a small comfort, however, when knee-deep in the medical profession. If there's one group of people unimpressed by someone being a physician, it's other physicians. In medicine, particularly in the training phase, guess who you'll be spending most of your time with? Likewise, most of the non-physicians you work with won't be overly impressed by your job. Nurses, pharmacists, PSWs, RTs, and the gamut of other healthcare workers have been around physicians long enough not to be in awe of the title. They will generally like you as a physician if you work well with them and do a good job for your patients, but will never like you because you're a physician.

The bottom line is that a prestigious career provides some benefits in terms of how you're viewed by others, especially those who don't know you well. When choosing a career based on prestige alone, you could do much worse than medicine. Yet, prestige is a weak and inconsistent shield against the judgments of others. Not everyone views physicians in a positive light, particularly those in regular close proximity to physicians. Therefore, as with any career, having the self-esteem to recognize who you are as a person, independent of how your job is viewed, is vital. If you don't have the confidence in your own abilities or value, being a physician will not provide much help to assuage those feelings. Similarly, if you do have confidence in who you are, that will show through regardless of what your career happens to be.

In the end, I believe that the prestige of the career is a positive reason to become a physician, but an exceedingly minor one. If a physician enjoys their work and the other aspects of medicine, the prestige of medicine is a helpful perk. For those that aren't as thrilled by the job itself, prestige is a poor consolation prize.

Considering a Career in Medicine - Money

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: Once established, a physician in Canada can expect to make a solid six figure income, with significant variation based on specialty, location, and practice type. However, it takes quite a bit of time and debt to become established. As such, delays in financing typical life goals are common. Money management skills are necessary to financial security, particularly when considering retirement, as physicians face different financial considerations than most individuals. Physicians often find themselves in trouble when they fail to control their spending habits and adequately save for the future. The high income in medicine is often a result of long hours worked, not just high hourly wage. Lastly, any career path should be considered with alternatives in mind, as students may have other, equally lucrative options.

Long Version: A desire for money is often thought of as an unsatisfactory reason to get into medicine, but money matters and income is an important consideration when planning a career. In Canada, physicians' income is high relative to most other countries, with the notable exception of our neighbours in the United States. There is significant variation in incomes for physicians. Specialty is the greatest factor, with lower-earning specialties like Psychiatry, Family Medicine, and Pediatrics earning closer to $200,000 on average, while high-earning specialties like Radiology or many surgical specialties earning in the range of $400,000 or higher. These figures are after accounting for overhead, but before taxes. Within each specialty there is a range of incomes as well depending on location, type of practice, and commonly performed services. It is not uncommon for practitioners to earn more - sometimes significantly more - than the averages quoted above.

Put simply, physicians have very good incomes, reliably putting them in or near the top 1% of earners in Canada. This high floor on earnings does come with a relative ceiling on income, however. Whereas similarly high-earning professions like law or business see elite performers earn several times what the average person in their field makes, physicians do not see that degree of stratification. The public healthcare system rewards quantity and with limited numbers of hours in the day, there's only so much physicians can do to see more patients and thereby increase their income. As a result, it is quite rare for a physician, even one in a high-earning specialty, to net over $1 million per year. Physicians are high earners, but students should not be expecting obscene levels of wealth.

Timing is also important when it comes to income and overall wealth generation, as the financial benefits of being a physician are not realized until after completing a long period of training, typically while accruing a fair amount of debt. A 40 year old physician tends to have more financial freedom than their peers in other careers. A 30 year old physician usually doesn't. This can complicate the achievement of non-career life goals that tend to occur in a person's late 20's or early 30's, such as buying a house, getting married, or having children, all of which carry a significant expense. All of these milestones are achievable as a medical trainee or recent graduate, but compromises are typically necessary. Some events will be delayed. Others will be lessened in scope - a smaller house, or a more modest wedding ceremony. Still more may be achieved only through added debt. Early career aspirations may need to take a back seat to income-generation. Over their career, physicians earn plenty of money to justify the initial time and debt invested, but the payoff is later in life, not earlier.

Once established, physicians' finances get easier in theory, but in practice, many continue to struggle. Physicians are notoriously poor money-managers and it can get them into serious financial difficulty. A mid-career physician has an enviable income, but can often set themselves up to have equally high expenses. After years of hard work and sacrifice, many physicians fall into the trap of spending too much and saving too little. This is particularly important as the vast majority of doctors do not have an employer-provided pension, meaning significant personal savings are required for a comfortable retirement. Jobs in medicine do not tend to have benefits either, residency being the notable exception, so physicians must also manage that expense out of their income. Failure to properly prioritize expenses through careful budgeting can leave physicians with significant money-related stress, despite having ample resources.

It should be kept in mind that the high earnings in medicine tend to come with long hours. Overall income can seem a lot less impressive when put in terms of an equivalent hourly wage, particularly once taking account all the unpaid aspects to a career in medicine. I hope to expand on this more in future posts.

Ultimately, when considering a career from a monetary perspective, a comparison must be made to alternative pathways, which can vary wildly person-to-person. If a student leaves undergrad with strong career prospects outside of medicine, they'll likely get far less of an overall gain from going to medical school than someone graduating their undergrad with zero immediate job prospects. In rare cases, going into medicine can be a financial negative. All students considering medicine should be actively developing alternatives to becoming a physician and should make the decision whether or not to enter medical school in light of those alternatives. Medical students tend to be intelligent, hard-working, communicative individuals who could be successful in a number of careers aside from medicine - it shouldn't be assumed that becoming a physician is the optimal choice from a monetary point of view, though it is often the lowest-risk pathway to ensure a six-figure income.

To sum up, there are some strong financial incentives to consider medicine. A physician can expect to be well-off to outright wealthy, but there are some caveats and physicians do need to budget their expenses to maintain financial security. Proper planning, with realistic expectations, is critical.

Advising Highschoolers and Undergrads on Medicine

If you're in high school or undergrad and interested in medicine, it's not hard to find opinions on whether you should pursue becoming a physician. Parents will weigh in, mentors will weigh in, classmates and friends will weigh in. Critically, physicians have their own views on whether prospective medical students should become doctors, and they tend to share those opinions, liberally. It is not difficult to find those viewpoints online or in print.

And those viewpoints are diverse. Very diverse. On one hand, which gets promoted by universities and physician organizations, you have the physicians who feel that medicine is a wonderfully unique career, that they derive immense satisfaction from, which is worth considering and striving for. On the other hand, which more frequently comes up in anecdotes of prospective medical students who have asked physicians they know about the field, is the notion that medicine will suck your life away with all its demands on your time and energy, and thus should be avoided like the plague.

So what's a potential future physician to think? Is medicine an incomparable opportunity for success, or a dangerous trap leading to unhappiness?

It'd like to come out and say the truth in somewhere in the middle, but I'd say it's more like it's both at once. It's undeniable that medicine provides many opportunities - both personal and professional - that are not easy to come by in other fields. Already, I've had the chance to see and to do and to experience more than I likely would had I stayed in my previous career. I have new perspectives I never would have experienced in any other profession. Yet, I've also had to give up a lot of things I care about to continue on in medicine, more than once going through long periods of exhaustion or being overwhelming, experiencing despair bordering on depression.

My expectations for life have been revised upwards in many ways, while being simultaneously revised down in many other aspects.

That may sound bleak, but I don't view it that way. Life is about making choices, and those choices come with consequences, both good and bad. We can't take advantage of every opportunity - our time and energy are limited. Going into medicine was a choice that has had some positives, some negatives. Some of these trade-offs I was aware of heading into medical school. Others I knew about, but failed to fully appreciate. Still others seemingly came out of nowhere.

When a physician gives a judgment on their satisfaction with their career, or their views on medicine as a vocation in general, they tend to be giving a summary opinion on those trade-offs, perhaps highlighting the good or bad aspects that matter to them the most in forming that opinion. Yet its digging into the trade-offs that the answer becomes clear and each person will place different value on the pros and cons of the profession. To make matters more confusing, as people grow over time and experience new elements of the profession, their viewpoints will change - my own verdict as to whether going into medicine was the right choice or not has jumped around multiple times and continues to do so, even after 4 years of medical school.

So, should a student considering medicine take the plunge? Maybe. It depends on a number of factors, including current situation in life, career alternatives, life goals or priorities, and personality. Making any career choice is too complex to put into a binary "yes-or-no" answer and apply it to everyone. That's doubly true for medicine, a field with significant sunk costs and limited opportunities to smoothly transfer to another career (especially early on). Sorting through the meaningful considerations is well beyond the scope of a single blog post, and should ideally involve an active conversation rather than passive reading.

However, recognizing that not everyone has a physician they can talk to in-depth about all aspects of medicine, I think it's worth having some general information available on what a student can expect from a career in medicine. Over the next little while in a series of posts, I would like to explore some of these factors in greater detail. I can't provide a full weighing of preferences, but perhaps I can provide some context.

Halloween

Today is Halloween! Well, when I wrote this it was Halloween, as of the posting time, yesterday was Halloween!

The hospital embraced the day, with so many employees dressed up. The pediatrics department, as usual, stole the show. Got to see a kid in a Minions costume! The facilities staff also stood out, a lot of very interesting (and surprisingly functional) costumes around.

I'm on a Psychiatry elective, which means dressing up is generally frowned upon. Tame costumes in appropriate circumstances only. Some of the patients got into the spirit though, which I just think is awesome. Definitely brightened up my day.

Anyway, here's hoping you're having (err... had) a good Halloween!

Bad Habits

Everyone has a few bad habits. These poor habits can be a significant drain on health and on quality of life. I think it's worth touching on one of mine as a follow-up to my previous post.

I get way too much screen time. I spend way too much time on my phone, computer, or watching TV. I'm on a primary care pediatrics rotation where I frequently talk about appropriate screen time for children (< 1 hr per day) and I can't help but feel like a huge hypocrite. The last time I got less than an hour of screen time in a day way probably back when I was a teenager and was camping out in the middle of a lake miles from any electronics.

Screens have become part of life for most people, so I'm hardly unique here, but my average day is probably about 75% screen time, if not more. It's a problem and one I'm definitely going to have trouble breaking. Realistically, I'm never going to be completely screen-free. I use screens for work, for school, for studying. It'd be impossible to function without screens in those situations.

However, there's a number of ways I can and should be cutting back on my screen time. First is with TV. I watch too much of it. I watch it reflexively. Don't even care if there's nothing on I want to watch, the TV is often there as background noise. We don't pay for cable either, so it's all Netflix or other streaming, not even something like the weather network or news.

Second is in keeping up with the world. The internet is great for getting news and discussing current topics, but it's also unbounded in these regards. There's always another viewpoint, another topic, another article that can be read. And I binge on this stuff. I don't think I'll ever stop this obsession with how the world works - it's part of why I went into medicine - but I would like to take some of these activities off-line. Once residency starts and I have actual money to spend, rather than a line of credit to increase, I'd like to start getting some print media sources. You know, actually pay for the information I get. If I can't break my information addiction, I can at least save myself some eyestrain while satisfying it.

Last and certainly not least - gaming. I like video games. And I have a history of video game compulsion if not outright addiction. I've probably spent about 10% of my total life - including time spent sleeping - playing one video game or another. My Steam collection has me at about 100 days of total playtime, which isn't too bad on its own, but neglects almost all of my major time-sinks. With certain games, I can waste an entire day without even realizing it. In the past, I've wasted far more than a day without realizing it. Sometimes days like this are benign or even helpful - a day off every once in a while is hardly a bad thing! But when it happens too often, happens when I really can't afford a day off, or happens without being planned, it just leads to more stress. Gaming is basically a hobby, and I need to be treating it like one, with regular, scheduled, and non-intrusive times set aside for it.

Getting more exercise and eating better were hard changes to make, but I think I've made a good start down that path. Cutting down on screen-time is going to be much, much more difficult.

Lifestyle Modifications

One of the things I've enjoyed about Family Medicine is that it's really the one area of medicine - aside from perhaps Pediatrics - that can get patients to start living healthy lifestyles before they develop disease. It's not a common occurrence - I've really only had a few patients come in where they were truly in a pre-disease state and could have their risk profiles change with lifestyle modifications - but in a medical system that is still primarily reactive, it's a valued opportunity.

For all our medical advances, nothing beats a healthy lifestyle to ensuring continued well-being. A balanced diet, sufficient exercise, adequate sleep, stress control, elimination of smoking, and moderation of drinking. For most patients, these six habits will do more to provide a long, happy life than anything any physician can provide.

These interactions have also been a great reminder to put the emphasis on my own health. Over the past two years, my health habits have fallen to pieces. I went from getting regular high-intensity exercise to getting virtually none. My diet went from reasonable-to-good to consisting of a lot of sugar-heavy foods. I started getting less and less sleep, of poorer and poorer quality (call and 5:30 am shifts didn't help much with this). Stress was naturally through the roof during clerkship. On the plus side, I fortunately didn't start smoking and my drinking stayed fairly moderate, so we'll count those as wins.

As I move out of the craziness of clerkship and onto the regular craziness of what will hopefully be the rest of my life, I'm trying to get some of those healthy habits back. I got a FitBit recently as a present and it's proved to be pretty good motivation (even though research shows it might be detrimental, at least to weight loss). I'm trying to push my daily steps a bit higher and I've started running again. On the sleep front, I'm now more aware of what helps me sleep soundly and what doesn't, thanks for FitBit's helpful - albeit somewhat unreliable - sleep tracker. It's also making me chart what I eat, which if nothing else is making me a bit more mindful of what goes in my stomach. It's led to some specific changes - since I was a kid, I'd have a glass of juice in the morning with breakfast. Every morning. While it gets presented as a healthy serving of fruit, juice is pretty much pure sugar with very little nutrition. I'm drinking tea now instead - never was a coffee drinker - and appreciating the change. Cutting it out eliminates a fair number of empty calories and tons of sugar from my diet.

I never want to be that hypocritical doctor lecturing my patients about good health when I'm not willing to make those changes myself. If only to understand the difficulty that can go along with making these positive lifestyle changes, I'm finding these new efforts worthwhile - and hopefully my own health improves as a result!