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.

The Rise of Anti-Aging Technologies

Anti-aging technology is a relatively small, but rapidly-growing sector of research and development. Several research groups have been established, both in academia and in the corporate world. The corporate side is particularly interesting as venture capitalists are starting to throw money their way and even some big players, like Google, have directly entered the market. In Google's case, its start-up Calico, is clearly well-funded but shrouded in mystery, with little information provided publicly and seemingly few connections with academics or other companies working on anti-aging approaches.

It's an intriguing concept from a physician perspective, since our work is directly towards the extension and improvement of human lives, and age is a fairly significant non-modifiable risk factor in many, many diseases. Yet, it's hard to know what to make of these research efforts given the grandeur and complexity of the task, as well as the relative opaqueness of the field. So, I was glad to come across this interview with Aubrey de Grey, who rather passionately makes the case for continued anti-aging research, its plausibility, its potential, and then responds to societal critiques against the notion of anti-aging research entirely.

Dr de Grey's viewpoints provide an excellent window into the field of anti-aging research, but I admit to being a bit unconvinced on several of his points. First and foremost, on the technological side, there's promise, but in many cases, little more than that. One example Dr de Grey points to is the use of stem cells in degenerative diseases, like Parkinson's. While research on this issue is on-going and far from being exhausted, the promise of stem cell research has been touted for a few decades now without much success in reaching clinical treatments. I fully expect some breakthroughs in stem cell research, yet it's hard to have confidence that these will come soon, or that they will be as all-encompassing as has at times been promised. More likely, we'll see slow, incremental progress. Considering Dr de Grey's anti-aging framework requires such ambitious goals as effectively curing all major cancers - and I'd agree that's a necessity to substantially extend human life given that cancer incidence rises quickly with age - there's good reason to be skeptical that technologies are close to achieving his aims.

Regarding the societal critiques, namely inequality and overpopulation, I also feel the tone Dr de Grey sets is overly optimistic. For inequality, we already see fairly significant differences in access to healthcare based on cost. Any anti-aging costs stand to be rather expensive, if the level of investment in the potential anti-aging technologies is any indication. Even in a socialized healthcare system such as Canada's, this will be a concern. One example that springs to mind is the introduction of sofosbuvir (Sovaldi) for the treatment of Hepatitis C. It is a very expensive drug, but because it is so effective compared to previously-existing alternatives, it is actually a fairly cost-effective therapy by current metrics. Yet, provincial governments have been reluctant to fully-fund this drug due to its high cost. In Ontario, the sofosbuvir is only covered if a patient with Hepatitis C meets one of several requirements, even for those with provincially-funded drug plans, despite the indication for sofosbuvir being much more expansive than allowed for by these requirements. Even though sofosbuvir is effective and cost-effective, its upfront costs present a challenge for cash-strapped provinces. This is all for a drug that hits only a sliver of the population. Anti-aging drugs, which could in theory apply to everyone, will present much more a challenge, even if they work exactly as intended for a reasonable cost.

Overpopulation is, in my mind, a bit of a non-issue at this time since I'm skeptical anti-aging technologies will see widespread usage, but assuming they do, it becomes a serious concern. Dr de Grey notes that those who live longer can also contribute to society longer and thereby produce enough resources to justify their continued existence. This is absolutely true, but runs into problems when resources are constrained by more than manpower. Without starting down a whole different tangent, we are hitting the point where natural resources, which are independent of human work, are depleting far faster than they are being replaced. On top of this, we have a huge swath of humanity living on fewer resources than most of us would consider acceptable. While I believe this is a surmountable problem, it's not an easily-addressed one. Indeed, the world has been failing to adequately manage the shortcomings in our usage of natural resources relative to supply for decades at least, despite concerted efforts by many committed individuals, non-profits, and governments.

Lastly, an additional societal concern wasn't discussed in the article - the value of human turnover. That's a morbid thought, but our society relies on people moving onto new things, retiring from the workforce, or yes, even dying, in order to continue advancing forward. Older people carry with them older ideas and are more likely to have build up the power to implement them. Some of these are worth preserving. Others need to be let go. Longer life spans and longer careers means established ideas stay established longer, less pliable to the innovations of the young. Once again, this is a surmountable concern, and societies could adapt to a new normal of long-lived individuals, but I wouldn't be confident that this would be a seamless transition.

In short, I'm intrigued, but skeptical of this renewed anti-aging push. There are technical challenges that are far from simple to overcome. There are societal challenges that would have wide ranging impacts if not adequately addressed. Whether anti-aging efforts see success or failure, I'll be keeping my eye out for updates in this field.

What's in the Scope of Medicine?

Physicians are privileged among healthcare practitioners in that medicine's scope, both functionally and legally, is essentially unbounded from a professional standpoint. While other healthcare professions are limited somewhat in what's considered their area of expertise, particularly from a legal perspective, physicians generally are not, with some obvious exceptions (dental work, for example).

Unfortunately, this also leaves unbounded the amount of information or expertise that could be considered worthwhile for a physician to learn. Any medical student past their first semester will have experienced this, sitting through more than a few lectures where some emphasized pieces of information appear to be relevant to the eventual practice of maybe 1% of the class only. Even as a future generalist, I can think of quite a bit that I've learned over the past 4 years that I will likely never have to use in clinical practice, even if some of my classmates will.

Physicians are also starting to explore areas outside of what is typically considered clinical medicine. For example, as the profession rightly acknowledges the high impact of social factors on health, medicine is slowly expanding to include, well, virtually anything. Everything from urban infrastructure, to primary education, to environmental regulations, to immigration, to energy policy touches on human health in significant ways. We have some teaching about these factors in medical school, but not overly in-depth, nor do we have time to touch on everything in society conceivably impacting health.

While I love learning about these "other" parts of healthcare outside of standard clinical medicine and finding ways to incorporate them into practice, it's unrealistic to expect me or anyone else to be masters of even a fraction of this material. This begs the question - what is essential for all physicians to know, and what is not? I don't believe we have answered this question particularly well and I believe it needs a good answer.

Physicians are fortunate to be able to push or around through the barriers that constrain other healthcare professionals from doing novel work outside their scope, because our scope is so ill-defined, and it leads to a lot of innovation within our healthcare system. That ability to innovate is worth preserving. The downside is that as we allow physicians to be just about anything these days, we've started structuring our medical education system to push physicians to be everything. This is neither realistic nor optimal.

At some point, we need to introduce more flexibility into our medical education to match the flexibility we expect from our practicing physicians. That means developing a core base of competency that is relevant to virtually everyone at that stage of training which is emphasized heavily, but then making much of what we currently teach non-mandatory. To compensate, more selective, elective, and extra-curricular education should be incorporated. Admittedly, this takes a degree of coordination medical schools and residency programs have not proven to be too adept at handling in the past. However, as medicine grows ever-wider, medical educators will have to start recognizing the limits of what can be taught and start seriously considering what should be taught, even if that means eliminating useful elements from what is currently part of the mandatory curriculum.

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.

Syrian Refugees

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

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

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

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

Depression in Medicine

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

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

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

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

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

Likes and Dislikes - Physical Medicine and Rehabilitation

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

1) Welcome to the Team

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

2) I Forgot Stuff... Lots of Stuff

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

3) Competitive

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

4) Happiness Test

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

OMA and Elections

The Ontario Medical Association is not popular. It hasn't been for quite some time - speaking with senior physicians, I seem to find no one who has nice things to say about the OMA as an organization - but the feelings towards the OMA seem to have declined even further since the tPSA debacle. It provided such a clear example of animosity between the OMA and its members.

The OMA has gone on a massive "reconciliation" drive, soliciting opinions from members and hosting meetings across the province. While welcome, these efforts seem to only underline that the OMA has no idea what matters to physicians, residents, and students, or what the situation is like on the ground for its members. There is continued skepticism that this effort will not lead to meaningful changes in how accessible the OMA is on a regular basis, how it operates, or how it makes important decisions such as negotiating with the province over physician funding. Frankly, much of the communications coming out of the OMA since the tPSA vote have been rather underwhelming, jumping between irrelevant to my situation, or well-intentioned but pushy (a recent advocacy drive fills my mailbox more than I'd like)

That's why I was pleasantly surprised to see a recent e-mail regarding OMA elections. I've now been an OMA member for 4 years. I have no idea how the OMA's leadership is chosen. I've voted in a district election a few times, but don't understand how the candidates I picked between were chosen, or what their responsibilities are. I've tried looking once or twice and came up short. I'm sure the information is somewhere and if I put in a concerted effort, I'd find an answer and ultimately, it is on me to be informed as to how the institutions I'm a part of run, but democracy - even in the confines of a private group like the OMA - shouldn't be that hard. Physicians are busy and can't devote endless time to wade through the intricacies of a group that is supposed to be representing their interests.

This lack of accessibility and transparency was certainly part of the frustration with the OMA in recent years. The OMA hasn't seemed accountable for its actions and the only way to get a say in the process seems to require significant individual effort, usually with little effect. One of the arguments from the OMA and OMA-supportive affiliated groups was that the tPSA had validity because it had been approved by democratically elected OMA representatives. When OMA members don't feel as though they had much say in any election, or that their representatives, well, represent them, it doesn't give much credence to the OMA's argument of legitimacy.

The election changes appear to move the OMA towards transparency and simplicity. Elections seem to be easier to participate in as a candidate and to vote in, with fewer barriers to being a nominated candidate, consolidated elections, and online voting. It's a small step. Probably not a big enough one. I'm skeptical this will provide enough benefit to truly reform the OMA's ability to engage with its members. Still, after a rash of empty promises or tone-deaf announcements, I'll consider this a positive change and leave it at that.

Beyond Pharmacare

It's more bubbling under the surface than being a headlining issue, but national Pharmacare is steadily becoming a major point of conversation within the medical community. Most countries with universal healthcare include some form of provision of pharmaceuticals, if not outright coverage - Canada is the notable exception. As such, Canada has now become a patchwork collection of private insurance, industry-provided samples or give-aways, public welfare programs, and out-of-pocket purchases in order to provide these drugs to patients. It's not a particularly efficient approach, with high costs for patient health, economic prosperity, or even balance sheets for government agencies.

What gets lost in the conversation is that when it comes to healthcare coverage in Canada, it's not just drugs that get the short end of the stick, it's most therapeutic interventions. Big, hospital-based treatments - surgeries, inpatient stays (including medication), dialysis, etc - are still covered, but non-pharmaceutical outpatient therapies rarely get adequate funding. The two that spring to mind most readily are physiotherapy (PT) and mental health therapies, notably Cognitive Behavioural Therapy (CBT). PT is a main component of treatment for most non-critical musculoskeletal injuries and in many cases, may be the only or main component to effective treatment. CBT is the first-line treatment for most cases of anxiety (which is exceedingly common) as well as a component in many other mental health treatment plans.

There are now some funded programs for both PT and CBT, but they naturally have long wait-lists. As a result, the rest falls on private insurance and out-of-pocket spending. The concern, as with medication, is cost. PT and CBT both involve having a qualified healthcare provider spend significant time with a patient. In-person contact is expensive and the public healthcare system is understandably hesitant to provide coverage, particularly if these treatments need to go on for some time.

In most cases though, neither PT nor CBT should go on for an extended period of time. PT and CBT have primary benefit when they teach patients exercises or skills to deal with their conditions. A single PT appointment may be enough in mild cases. CBT requires a few more, but a short course is often sufficient if the patient is compliant and motivated. There's always the possibility of therapy needing to go on longer than intended - but the same can be said of medication.

I'm very hopeful that Pharmacare becomes a reality - I've already seen far too many patients struggle with getting necessary or helpful medications. No doubt more fail to get important medications without their healthcare providers being aware, as research on compliance with medications in the setting of economic difficulties makes absolutely clear. Yet, as coverage for medications expands, I do worry about these outpatient-based, non-pharmaceutical therapies falling by the wayside, especially when these interventions are often more effective than pharmaceutical alternatives. Looking towards my future practice, I find myself taking a decidedly "drugs if necessary, not necessarily drugs" attitude. I want a public insurance system that supports such an attitude.

CaRMS Cycle - Go Time

So, the new CaRMS cycle started this week. My CaRMS cycle.

It's a very weird feeling, having residency start to become a reality rather than an abstract concept in the future. Before this week, anything I did - aside from passing all my courses and rotations - only had a tangential effect on my residency chances. Now it's all quite direct, and that is... well, a little stress-inducing.

Don't get me wrong, I've got months to get things ready and have put myself in a reasonable situation. Most of my documents are already prepared. I've only got a few personal letters and letters of reference to arrange, but not too much else beyond that. Still, I've had months disappear on me in the blink of an eye, so I don't want to get complacent.

On the positive side, it feels like I'm coming to the end. I'm done my pre-clerkship courses, the ones I merely tried to get through while doing as much as I could outside the standard curriculum. I'm finished clerkship, where I largely enjoyed the work, but detested the working conditions and treatment of patients for many rotations. Someone reminded me that, because I'm going into Family Medicine, the required part of my training to become a fully qualified, independent physician is now over half complete.

I can't wait to start working. I know I have a lot to learn before I'm able to do that, but I'm so excited to get to that point, to be finally done with my formal education and onto learning for life instead.

So, as stressful as this is, starting my CaRMS application is a great step to be allowed to take. It signifies that it's time for the next stage of my training. I'm quite thankful for that opportunity.

Likes and Dislikes in Anesthesiology

For a number of reasons, I didn't get much time on my Anesthesiology rotation. That's a shame, because it was quite enjoyable! Here are my Likes and Dislikes.

1) Anesthesiology is not boring

The stereotype of the anesthesiologist slumbering behind the curtain is still alive and well, but I found myself to be quite busy when on the service. The actual act of putting someone under general anesthetic, sedation, or otherwise providing pain relief is not a simple process. There is a lot of preparation and planning that goes into it. Deciding what supports are needed, from the type of respiratory support, to the number of IVs, to the presence of an arterial line takes some quick decision-making. Securing all these supports, especially in the fast-paced setting of an OR, is not an easy task. Intubating is hard, and I failed at it, a lot!

2) Ok, sometimes Anesthesiology is boring

In ORs with regular turnover between cases and reasonably complex anesthetic requirements, there is plenty of action. In ORs where neither of these is the case... well, it can get pretty dry. Cases that last for half the day mean hours of sitting doing not a whole lot for Anesthesiologists. If the patient becomes unstable or threatens to, then things can get interesting, but that happens relatively infrequently, a testament to the efficacy of what Anesthesiologists do. On the other side, cases which only require mild or moderate sedation do not involve much preparation, and so tend to proceed like clockwork. I still found these cases interesting for a few weeks, but I doubt I'd be able to sustain interest for years or even months.

3) Teaching, teaching, teaching

Anesthesiologists, at least the ones I worked with, were really great about teaching. I got to go over a wide variety of topics not just once but multiple times. Aspects of medicine I hadn't touched on previously were like second-nature after finished the rotation. Even with limited time on the rotation, I felt like I got a lot of key points of my education covered thoroughly, simply due to dedicated teaching time and repetition of important elements. I really wish more of medicine had the degree of emphasis on teaching and focus in topics as Anesthesiology seemed to.

4) Happiness Test

Anesthesiologists seem pretty happy. Sometimes a little bored, no doubt. Saw more than one playing Candy Crush during an OR. I think the downtime helps though. Medicine is such a whirlwind, it's easy to get caught up in it. Anesthesiology comes with built-in breaks, slowing things down even if just by a small amount. A little bit of boring can be enormously beneficial.

How Empathy Declines in Clerkship

An interesting (albeit far from robust) finding in the literature on medical education is that empathy tends to drop like a rock in the 3rd year of medical school. This is obviously not true for everyone - in particular, those coming in with high empathy tend to maintain their empathy levels better than those starting with lower empathy - but declines can be seen throughout the spectrum.

It's one thing to read about on paper, it's another thing to experience first-hand. Without a doubt, I believe my level of empathy - both internal and expressed - has fallen this year. I'm not happy about it and actively working to develop habits to bring it back up, but I can't deny that it happened. Especially on my final rotation through surgery, I caught myself tolerating or even engaging in behaviours I would have considered unacceptable a year ago. Part of addressing this setback in my ability to be a competent, empathetic physician involves identifying the causes of my decline in empathy. Here's what I've come up with.

1) Role Models

Medicine is hierarchical. We learn from those ahead of us and model our behaviours after our superiors. When the staff and residents we train under fail to show empathy, or when we're simply never around when they do demonstrate it, it conditions us students to de-emphasize empathy in our actions as well. I've seen such a spectrum, from exceedingly empathetic physicians and residents, to exceedingly unempathetic physicians and residents, but most fell somewhere in a neutral area. They'd be empathetic when convenient and when it was obviously useful for their sake, but wouldn't put in the effort when empathy was inconvenient or when the benefit was primarily for the patient's sake.

Monkey see, monkey do.

2) Ain't Nobody Got Time For That!

Medicine is busy and very fast-paced. There is constant pressure to do more with less time. The problem is, empathy takes time. It doesn't have to take a lot of time, especially for practiced individuals, but being unempathetic is undoubtedly faster than, you know, actually connecting with patients. When workflow is not set up to allow for empathetic communication, it becomes the first thing to go. Priorities in evaluation or compensation play into this, as students, residents, and staff are far more likely to benefit by being fast than by being empathetic. Ultimately I think being an empathetic practitioner leads to higher job satisfaction, and there are some small awards in medical school, residency, and practice for consistently demonstrating empathy, but the main external incentives are still in favour of going fast above being a compassionate, empathetic practitioner.

3) Active Discouragement

It's less common than the above examples, but there were times where being empathetic was actively discouraged. There are some practitioners who don't believe in empathy as a useful clinical approach, at least not in all situations. I have experienced a physician essentially yelling at a patient for being overweight. I was once called out for being too empathetic in a situation where my supervisor believed it was unnecessary. In fairness, there are absolutely circumstances where overt empathy needs to be toned down or even eliminated because it ends up being counterproductive. In psychiatry, for example, practitioners do need to be conscious about being too overtly empathetic because it can harm the therapeutic relationship. Yet, I found that about half the instances where empathy was being discouraged, the justification was more about convenience than about what was in the best interests of the patient. I found these pressures against empathy easiest to resist because they were so overt, but it was a pressure nonetheless, and contributed to a culture in some parts of my medical training that clearly did not value empathy in medicine.

4) Exhaustion

The spectre hanging over all of this is the chronic exhaustion inherent in much of medicine, particularly during training. Sleep deprivation distorts people's natural emotions, affecting mood, memory, and overall cognition. One notable effect is to make people irritable. Irritability isn't incompatible with empathy, but it certainly makes it a lot harder. Empathy requires a degree of emotional self-regulation and irritability reduces the degree to which emotional self-regulation is achievable. Sleep deprived practitioners can still keep it together, but that control is not as endless as it is in rested individuals. It does make me understand one of the less-appreciated coping strategies for exhaustion - maintaining calm around patients, but being quick to anger around learners, fellow physicians, and other healthcare professionals - though those actions don't exactly help the culture of medicine overall.

There is a second meaning to the title of this section. Compassion fatigue, the challenge of caring about the 100th patient suffering with a given illness with the same intensity as the 1st, is extremely common among healthcare practitioners. It's difficult to avoid, as we become accustomed to the tragedies of illness we encounter on a daily basis, but which are completely novel for our patients. I find this particularly common with conditions that are merely disruptive, rather than debilitating or fatal. When morbidity and mortality are common experiences, empathy for those who are inconvenienced is hard to muster. A truly empathetic person should be able to cut through this fatigue - after all, empathy doesn't mean feeling the same way as another person, but rather understanding they way they feel, even if you wouldn't having similar emotions in the same circumstance. Nevertheless, empathy is easier when your natural emotions more closely align with those of your patient, and compassion fatigue often causes that alignment of emotions between physicians and patients to slowly widen over time.

Solutions

I have no easy answers for reducing this decline in empathy through clerkship. On a personal level, I try the standard approaches - getting a bit more sleep, spending time with people outside of medicine to ground myself a bit, keeping mindful of my actions, and using reflective techniques like this blog. The medical profession in Canada has started putting an emphasis on physician resiliency and I do believe these efforts can be beneficial in preserving empathy through training.

However, the problem isn't with the people going through medical training - many of my fellow classmates enter medical school as some of the most grounded and resilient people I've met. Falling empathy is a systemic problem and requires a systemic solution. Reforming the medical system to allow for sufficient rest, and then to prioritize empathetic communication, will take hundreds of changes, both large and small. The good news is that if we can make enough change, the positive effects will propagate. Hierarchy in medicine means negative qualities persist from generation to generation, but so do useful qualities. The more empathy supervisors show, the more empathy learners will as well. In the meantime, individual-level interventions will have to suffice.

Likes and Dislikes in Surgery

For non-surgeons, the surgical rotations are always a bit of a trial. The surgical/medical divide is real so spending months on the other side of it can be a challenge. I guess clerkship's worse for the surgical gunners though - I only spend 3 months or so in surgery, but they spend almost all of clerkship out of it!

Anyway, continuing on with my series, here is what I liked and didn't like about my surgical rotations.

1) I get bored during operations

I encourage everyone to step into an OR or two early in pre-clerkship. Surgery, despite it's terrible job market and long hours, is still very competitive overall and it's worth knowing whether you may need to push for it as a potential residency option. My guideline is that when you step into the OR, unless it's something obscure and weird, you have to love what's going on. Being interested isn't enough - the road to becoming a surgeon is too long and arduous to sustain mere interest, you need to be enraptured by the whole thing.

The first time I stepped into the OR I was, at best, mildly intrigued. I knew at that stage that I wasn't a surgeon. Now, after months in there, I'm downright bored. I understand the basics of what goes in the OR and the details don't interest me in the slightest. Definitely not a surgeon.

2) Love the surgical attitude towards medicine

When it comes to medical management of patients, nothing beats the typical surgeon attitude - they're clear on what they do and what they don't do. What they do they do quickly and efficiently. No debating things back-and-forth for half an hour - a decision gets made that's that. That does mean some things they probably could/should handle they pass off to others and, in an ideal world, physicians would take responsibility for the totality of their patients, not just the parts they want to manage. However, the alternative I've seen has been physicians trying to do too much and stepping on each others' toes, creating confusion for patients and providers alike. Again, in an ideal world, stronger communication between physicians would occur to address this problem, but clearly defined roles can be an enormous benefit whether proper communication occurs or not.

3) Don't love the surgical attitude towards people

Surgeons can be judgmental. Really judgmental. Of patients, of physicians (especially non-surgeons), of other healthcare staff. Don't get me wrong, physicians in general are fairly judgmental as a group, but surgeons seemed to be more blatant about it. Some of the attitudes and statements bordered on unprofessional. As with most places, it was a distinct minority who were the main culprits in these activities - in fact, some of the best staff and residents I've worked with were on my surgery block. However, that minority was entrenched enough and vocal enough that they seemed to influence the overall culture. A physician or resident who was needlessly harsh on a patient, subordinate or colleague was often encouraged or at least tolerated. On the opposite side, kindness and understanding were occasionally mocked. I have no doubt that these were meant as jokes without maliciousness, but that seems a distinction without a difference - in either case, a negative attitude towards others was fostered.

4) Long hours, little sympathy

It goes without saying, but hours in surgical specialties are LONG. 10 hours at the hospital is a short day. 12 is typical. 13 is within the normal range. All told, on average and after considering things like travelling to the hospital or doing the bare minimum to perform my clinical duties, I had between 10 and 11 hours of my own time for non-call days. That's as little as 10 hours to eat, sleep, study, exercise, spend time with my SO and my dog, and pretend to be a normal human being. I mostly ended up shorting myself on sleep and exercise to preserve a tiny amount of time with my SO and to study. It was sheer exhaustion and I feel like it's going to take a long time to recover from this level of fatigue.

Of course, as a student, you get zero sympathy. Residents work even longer hours, with more responsibility, and have been doing it for years. Staff went through the whole process and still tend to work long hours deep into their careers. Moreover, it wasn't too long ago when students had it much, much worse. Still, better doesn't equal good, and we're still a long, long way away from having anything resembling reasonable working hours in surgery.

5) Camaraderie

Surgical departments are small. There aren't that many staff and the number of residents coming through each year is considered large if it hits half a dozen. Many surgical residency programs take only one or two each year. Over the 5+ years, it does become obvious that the staff and residents end up knowing each other well. The residents especially seem to understand that as hard as it is to get through their residency, they're in it together. The best way I can describe surgery is like being in a frat, with both the good and the bad that come with it. The familial, laid back atmosphere was definitely a positive, and in sharp contrast to some larger specialties that weren't nearly as closely knit.

6) The Happiness Test

Are surgeons happy? Nope.

Ok, ok, it's not that clear cut. Many seem to really enjoy their work, especially when they're at the staff level and in the operating room. Yet, by and large, I didn't see many overly happy people. Frustration and exasperation were common occurrences. I wasn't the only tired person there, it was obvious on the faces of some residents and staff. They were determined and resilient, but it's hard to call someone happy when they're still in the middle of the fight.

Everyday Sacrifices

Becoming a physician is about making sacrifices. There are ways to mitigate, minimize, and tailor those sacrifices, but as a whole, they're unavoidable. We give up our 20's and in many cases a fair bit of our 30's to become a physician. We give up nights out partying or relaxing with friends to study, to do research or other projects, to spend long days at the hospital. We give up time with our families, or delay having a family, in order to complete our training successfully.

There's really no getting out of these aspects of medicine, they're inherent in the profession and its training.

However, we also want physicians who are willing to make additional sacrifices for the sake of their patients. Physicians who will forego a little income to provide a good service on a regular basis. Physicians who will make an extra call to get their patients the supports they need. Physicians who will stay a little longer at the end of the day for a patient in crisis. It's far too easy to phone things in in this profession, to our patients' detriment.

That said, medicine has a problem with indiscriminate sacrifice. Medicine tends to encourage and incentivize physicians giving more of themselves without considering what the sacrifice is for, or whether it is even helpful.

Two scenarios that have happened often enough jump out at me.

1) Blatant Benevolence

A play on the concept of conspicuous consumption, where people buy expensive things essentially for the sake of showing they can buy expensive things, blatant benevolence is the idea of doing something good because of the reputation it garners. The original concept was applied to mating preferences, but the term has broader applications. In medicine, that means staying late, coming in early, taking on an extra patient or doing some additional grunt work. The idea is that these actions show desirable qualities to colleagues and superiors.

The important point here is that with blatant benevolence, it's the perception resulting from the actions that matters, not the effect of the actions themselves. There are, of course, instances when coming in early, staying late, or taking on an extra patient is extremely helpful and especially at the trainee stage, most people are eager to take these opportunities to demonstrate their commitment or ability.

It's when these actions are not helpful that the profession runs into trouble. Students pre-rounding an hour before their shift starts when no one asks them to. Residents staying hours after their shift ends to watch over a patient who they've already ably handed over to the next team. Staff sticking around to handle tasks that would normally go to residents for their learning. These actions clearly show that the physician or trainee puts medicine first and foremost, but don't add value to their patients' care and could be taking opportunities away from others.

We're thankfully moving away from these pointless shows of sacrifice, but it's still very much a part of medicine. Maybe 1 in 5 trainees seem to engage in this sort of behaviour regularly, but just like with conspicuous consumption, those who do engage in it pull others with them moving forward. A decent number of trainees come in with the idea that they must show. Which brings us to the second scenario...

2) Extraordinary Actions in Ordinary Times

Physicians are the first and last line when it comes to healthcare. When something falls through the cracks, we're expected - and even have a legal obligation - to pick it up. Medicine has a lot of cracks, however, so things slip through regularly. And dutifully, physicians respond by giving up even more of their lives to help their patients.

These actions are essentially required in medicine. The notion is that these are unpredictable events and so it is up to physicians to provide the flexibility necessary to respond to them.

When the extraordinary happens on a regular basis, it's no longer extraordinary. It's no longer unpredictable. Yet physicians continue to react to these commonplace occurrences as though they're extraordinary and unavoidable.

A physician staying late once a month is totally reasonable. A physician staying late once a week is troublesome, but manageable. Yet when I see physicians - particularly residents - staying late multiple times a week, it's no longer about physicians sacrificing for their patients, it's now physicians sacrificing for a poorly-run system.

Worse, when the extraordinary does actually happen, physicians may not have the ability or willingness to make that extra effort. They're already pushed to their limits with their regular expectations. Very few physicians are truly indifferent to their patient's interests, but fatigue and burnout can mean important but non-critical tasks get delayed, ignored, or rushed.

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I heard an older physician remark recently that my generation of medical students doesn't know the meaning of sacrifice. Certainly, what my generation seems to prefer and tolerate differs from the expectations of some of our superiors. However, I don't consider that to be a negative. What we consider a worthwhile sacrifice needs to be refined. There are some sacrifices made by established physicians I never want to make. Yet there are other sacrifices these physicians tend to avoid that I'm eager to make. Recognizing that physicians are human, that they have their limits and in normal times should lead reasonably normal lives, we need to be smarter about what sacrifices we choose to make or to ask each other to make.

Likes and Dislikes in Radiology

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

1) Imaging is great for learning, especially anatomy

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

2) More patient interaction than expected, still not enough

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

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

3) It's tough to be a student

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

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

4) The Happiness Test

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

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

CaRMS Match 2016 - Further Thoughts

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

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

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

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

Exactly Right
Orthopedic Surgery
Psychiatry

Within Margin of Error
Family Medicine
Ophthalmology

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

Crazy Wrong
Internal Medicine
Physical Medicine & Rehabilitation
Urology

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

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

2) This year's match was competitive

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

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

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

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

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

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

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

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

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

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

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

Likes and Dislikes in Family Medicine

Whew... I'm coming to the three-quarter mark of my clerkship rotation, just finishing up my Family Medicine rotation and staring down the barrel of my final rotation in Surgery. Time for another "Likes and Dislikes" post. Full disclosure - I've pretty much settled on applying to Family Medicine come CaRMS time, so this post may be a little bit biased...


1) Continuity of care is awesome
Getting to see the same patient multiple times in the same rotation is not only gratifying but great for learning. The rest of clerkship is incredibly fragmented - aside from inpatients who we see for as long as they're in hospital, clerks usually don't see a patient more than once. Here, I got to see the results of some of my diagnoses and treatment plan. It makes the experience a lot more memorable, makes care a heck of a lot easier, and makes learning that much more enjoyable.

2) Some people are a drain on healthcare resources
It should go without saying that same individuals consume more in healthcare funding than others. In family medicine, it was pretty easy to pick out the frequent visitors. If all a high-volume healthcare user does is come to their Family Physician too often, we're not in bad shape - FM visits don't cost much at all - but the spiral in costs from that point definitely adds up. Lab tests, imaging, consults...

In some cases these costs are justified and provider-driven. Someone at high risk of cardiac problems will get a lot of attention from their Family Physician and rightfully so. Some are... less beneficial. Anxiety takes a huge toll on the healthcare system in ways that have nothing to do with managing anxiety. Likewise, patients with significant social dysfunction inevitably find their way into interacting with the healthcare system for relatively non-productive reasons.

All this said, it's all too easy to blame the patients themselves for this overuse, particularly for a primary care provider dealing with the same person over and over again. These patients all have problems that deserve attention, it's just not necessarily the problem they're putting to the physician. Healthcare has its limits and in terms of improving health, it's only one part of the solution.

3) Why are regular hours a bad thing again?
I haven't worked a night for almost two months now. I have small but discrete periods of time in the morning and evening to either relax or work on side-projects. I'm getting exercise again, if only small amounts. Yet I feel like I'm learning about as much as I was during my more "intensive" rotations. This is undoubtedly where my preconceived notions come into play, but I'm still baffled why medical education is so set on the idea of long, intensive hours, particularly at this stage in the game. More experience is undoubtedly helpful, but fatigue is undoubtedly hurtful. It has been good to feel relatively rested again.

4) Rush, rush, rush
The main downside I see in Family Medicine is a strong incentive to rush patient visits. The economic constraints require seeing a lot of patients as quickly as possible in order to cover overhead. I had dreams of a practice where my patients were scheduled every 20-30 minutes and I could really take my time with my patients. Now, I don't believe that's feasible in most set-ups. Billing codes in Family Medicine are just too low to allow for deep, methodical visits like that on a regular basis.

However, they may not be necessary either. It's taking me about 30 minutes per patient right now, but that's considering I'm dealing with conditions I'm still learning about, patients I don't know, working within someone else's system, and having to review all my patient encounters. With some more knowledge, familiarity and independence, I can see 15 minute visits being enough. I wouldn't want to push it much faster than that, as I know some physicians do, but a snail's pace doesn't seem like a great idea either.

5) The Happiness Test
This question worried me a bit for this rotation because I've become fairly set on Family Medicine, but to my relief I'd say yes, they are. The paperwork seems fairly excessive and physicians who get caught up in the daily grind seem a bit disheartened, but there's room for a diverse practice to balance things out. The favourable job market and wide flexibility of location are helpful as well - where you work and who you work with matter significantly in terms of being happy at work. I think I'll welcome having a little bit of choice when I eventually establish a practice.

Medical Blarg - Where to Start

Despite my best efforts, this blog is getting a bit more readership, so I figure it's time to get some things organized around here. This post is meant to be a place to start for new readers at various points in training. My posting thus far has not been organized, so the posts don't necessarily flow into each other, but they should give you a sense of who I am and the opinions I hold.

This is also my opportunity to encourage those lurking around to comment on posts. I never really intended this blog to get much readership, but there's a reason it's a publicly-accessible blog and not a private journal. I want feedback on the things I write! Especially for those who might disagree or have a contrasting opinion to offer, I'd love to hear it.

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For Those Considering Medicine
Back Up Plans
You Should Study Something You Enjoy

For Those Applying to Medical School
On Giving Advice About Medical School Admissions
Should You Study Medicine Abroad?
If I Don't Study Medicine Abroad, What Are My Options?

For Those Trying to Choose a Specialty
How To Pick A Specialty
Preparing to Match in CaRMS (Before Knowing What To Match Into)
How To Pick A Specialty - A Follow-up

My Likes and Dislikes in...
     OB/GYN
     Pediatrics
     Emergency Medicine
     Oncology
     Internal Medicine
     Psychiatry
     Family Medicine
     Radiology
     Surgery
     Anesthesiology

My Thoughts on Medical Education
Fairness in Medical School Admissions
What Should Medical School Admissions Look Like? (Part I)
What Should Medical School Admissions Look Like? (Part II)
Med School Curriculums Across Ontario
Underpants Gnome Theory of Medical Education

Miscellaneous
Reading About Healthcare
It's Alright to Hate Medical School

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Ultimately this is a personal blog, more like an open diary than anything else, so I post about whatever comes to mind. This is how I express and reflect on my random thoughts.

I find in medicine it's too easy to get stuck on autopilot, or to feel caught on whatever treadmill I've put myself on. This blog is my effort to turn off the autopilot, to step off the treadmill if only for a few minutes.

What I hope for those who stumble across this blog is that you'll leave with something to think about, even if that thought is "wow, that guy was totally wrong!"

Happy reading!

How To Pick A Specialty - A Follow-up

It's been a bit less than a year since I made this post about picking a specialty, where I described the approach I took to narrowing down my specialty choice. Now that I'm done the majority of clerkship and am coming around to a final decision, I figure now's a good time to follow-up on that post to reflect on where my approach worked and where it might have fallen flat.

At the end of second year, my list of specialties, in no particular order, looked like this:

Diagnostic Radiology
Emergency Medicine
Family Medicine
Internal Medicine
Nuclear Medicine
Obstetrics & Gynecology
Pediatrics
Physical Medicine & Rehabilitation

Now, it's a bit smaller and it has an order:

1. Family Medicine
2. Pediatrics
3. Emergency Medicine
4. Psychiatry
5. Radiation Oncology

Two things to mention. First, a number of specialties dropped off my list. Two fell off because of less-than-great experiences in clerkship (OBGYN, Internal Medicine). A few fell off due to attrition - I didn't necessarily have bad experiences with these specialties, but I had enough good experiences in other specialties to feel comfortable eliminating them. That's all in keeping with my original strategy for picking a specialty.

Secondly, and decidedly not in keeping with my original strategy, you'll notice two specialties that weren't on my list from a year ago. I had a really good experience in Psychiatry, which I wasn't expecting. I also had a great experience in Oncology, which I was expecting, but even then the rotation exceeded my expectations.

Many residents and clerks say that you really won't know where you stand on a specialty until you experience it. I'm inclined to agree.

Nevertheless, I think my approach still has some merit. My top three specialties are ones I was considering heavily prior to clerkship. The specialties that jumped onto my list aren't overly competitive - if I wanted to, I could still make myself a reasonably attractive candidate for these fields by re-arranging electives, doing side projects, etc. Eliminating a good number of specialties because of more superficial attributes (hours, patient population, job market) proved reasonably useful because at the end of the day, they still factored into my final ordering. Radiation Oncology, for example, fit my preferences extremely well. However, its job market is pretty bad and flexibility of location is rather limited. Despite defying expectations and making my short-list, it's at the end of that list and will not factor into my elective planning.

Still, I did give too my credence to reputation about specialties, Psychiatry in particular. It hit my goals for those lifestyle-focused parameters, yet I wrote it off prematurely due to perception of the practice rather than reality. I wish I had explored it more thoroughly in advance of clerkship. It's important not to pre-judge the actual practice of a specialty until you see it first-hand.

Dogs and Random Encounters

I have a rather energetic dog, who needs a lot of walking. Inevitably, he meets other dogs on these walks. I then meet a fair number of other owners. Not all of them I particularly want to talk to, but most are good for a conversation and it's a great opportunity to get some perspective on life outside of medicine.

I've had the good fortune of meeting a few people who have physicians in their lives, including some physicians I've met through medical school. It's been very revealing to get an outside perspective about the benefits - and challenges - of being a physician. In particular, I've appreciated hearing the effects of the career on the physician's family. Medical training is tough on the person going through it, but I'd argue it's just as tough if not tougher on their family. Some of these conversations have been good reminders that I'm not in this alone and that I need to consider the effects my career is having on those around me, particularly my partner through all this.

It also touches on a central criticism I have about medicine as a discipline - we're too separated from the patients we serve. Most physicians come from wealthy families, went straight from the academic bubble to the bubble of medicine, and then end up as a reasonably wealthy physician. Physicians live in nice but expensive neighbourhoods, their kids go to good schools (often private schools), while their vacations and hobbies are often pricey and/or eccentric. A typical physician has little free time and few intrinsic ways to interact with those not in healthcare or not at a high socioeconomic level.

Yet, people of all backgrounds own dogs. And through my dog, I get to meet a lot of them, even as I'm knee-deep in the muck of medical training. It's not much and I don't feel nearly as grounded in my community as I did before medicine (or at least before clerkship), but it's better than nothing. This is one of the many reasons I'm thankful for my furry companion.