Match Day - Tomorrow

Ugh...

Argh...

Ahhh...

So, tomorrow's match day. I've been trying to distract myself from that fact for well over a week now and my level success is pretty low at this stage. At noon, I find out my fate moving forward. So does the rest of my class. For the record, communal anxiety is not helpful for personal anxiety!

My school has done the only thing that makes sense to me and gives us the whole day off. I think I could have tolerated morning classes, but having the afternoon off is a huge relief. Whether I'm happy, sad, or just confused, I'll have the time to handle it on my own terms, rather than have to deal with a bunch of lectures, tasks, or people I'd rather just avoid. Apparently years ago they used to hand out sealed envelopes to everyone in the same room and you were supposed to open them together. That sounds mortifying.

In any case, thumbs up to the home school for doing the right thing. Here's hoping I get to use that time to celebrate.

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!

CaRMS In

After much scrambling, managed to complete my CaRMS applications on time. Personal letters got done at the last minute and I submitted everything far later than I'd like, but it's all in. My letters of reference were received in good time and all assigned already, so I don't even have that second reference letter deadline to worry about. It's all in, complete and done.

Posting has been a little bit delayed and will likely stay that way as I catch up on missed sleep, but it feels great to have a bit of extra time to get back to blogging. Expect to have some meatier posts in the near future.

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.

Bizarro World

Medicine feels increasingly like Bizarro World, where everything's upside down but no one seems to notice. Things other professions would consider completely unacceptable pass as unremarkable in medicine. Sleep, bathroom breaks, sometimes even food are all considered non-essential. Penny-wise, pound-foolish approaches to delivering care are common, despite massive shortfalls in funding. Accountability is laughable unless a mistake is particularly egregious. Even achieving marginal change seems like a hopeless uphill battle in many instances.

What's been helping me get through these everyday absurdities are the rare moments when those ahead of me in the system, or even my fellow clerks, openly acknowledge that what's going on is utterly insane. Clerkship is amazing in that you finally get the opportunity to do some hands-on medicine, or at least hands-on learning, but it's pretty isolating too because so much of your interactions are work- or school-related. So, frustrations don't always get discussed much, particularly with those ahead of you (since you're also trying to impress them).

When the facade comes down, even if just it passing, I find it incredibly rejuvenating. It's like being in the story of the Emperor's New Clothes. You know the Emperor's not wearing anything, but everyone's acting like he's not completely nude. When someone says "Hey, isn't it weird that dude's naked?" it's like validation that you're not insane, that the world isn't completely turned upside down.

Anyway, just wanted to express my gratitude for those who are willing to complain a bit. Sure, fixing the problems in medicine would be the ideal actions to take - just like giving the Emperor a fig leaf or something would probably be a good idea - but when that's feasible, acknowledging the day-to-day craziness in medicine has proven pretty cathartic.

Burnout Culture

Really wanted to highlight a post via KevinMD of a burnt-out surgeon. First, I think it gives a good description of how medicine leads to burnout, namely that it's a long process. Individual  moments certainly stand out and can precipitate reactions like a breakdown or quitting, but a physician is set up to break long before any one event pushes them over the edge.

Second, stresses on a physician are multi-factorial. One of the commentators provides a nice framework to categorize the stresses:

1) Workload - too much work, long hours, not enough time for each task
2) Control - limited autonomy, limited schedule control
3) Reward - insufficient monetary, non-monetary, or personal compensation
4) Community - lack of sense of belonging, difficult coworkers or bosses, habitual conflict
5) Fairness - unequal treatment between physicians, or unjustified treatment of all physicians
6) Values - work that conflicts with your broader ideals

Every job has concerns related to some of these categories. What the burned-out surgeon's story makes clear is that many physicians are having stress in almost all these areas: long hours, too much work in those long hours, little schedule control, inadequate support from colleagues, the list goes on. Each physician will have their own mix of personal stresses, but it doesn't tend to be a single one that causes a physician to become burned out, it's the combination of stresses that does it.

Some stresses in medicine are going to be unavoidable. A regular, 40 hour work week for all physicians probably isn't viable without massively slashing overall compensation or having physicians provide horribly substandard care. Full schedule control is impossible in many specialties. Some conflicts between physicians are necessary, even productive.

Yet, there are a lot of stresses physicians face that could be minimized or eliminated. 40 hour weeks may not be feasible, but that doesn't make 60, 70, or 80 hour weeks necessary. Coverage for 24/7 services requires people working when they'd probably rather not and while night shifts are never good for a person's health, many workplaces figure out how to employ people at all hours of the day without causing the system-wide levels of stress seen in medicine. Open conflict between physicians is actually quite uncommon I've found, yet a degree of animosity towards other physicians and healthcare workers seems to run deep and it's completely unnecessary.

The author of the article is American, and the US healthcare system does have its differences relative to Canada, but the contributors to stress are very similar. The major salient difference may work in our favour - while in the US, physicians are often hospital or clinic employees, subject to the whims of their employers, Canadian physicians typically function as independent contractors of sorts, with more collective leeway to make positive changes to reduce our own stress. While our American colleagues are largely confined to railing against the system controlled by non-doctors, Canadian physicians just need to convince each other that this is a problem worth addressing.

However, as the piece laid out, fellow physicians can be the greatest obstacle in taking care of ourselves. Calls for help frequently go unanswered and resentment absolutely exists for those who work less in an effort to recover from or prevent symptoms of burnout.

I think we're getting there, all barriers aside, and while change has been frustratingly slow, it's at least moving in the right direction. Yet, as anecdotes like this make clear, there's good reason to pick up the pace.

Minor Pre-Residency Rant

So our school just had a Career Day, where all the program directors and quite a few residents came out to talk about the residency programs at our school with us medical students. It was really well done and everyone I spoke to was extremely helpful. I came out of it feeling like I knew at least somewhat where I stood at each of the specialties I'm interested in here. Since I would prefer to stay in this city for my residency, that becomes extraordinarily useful information. I can't say enough about how much events like this help me as a student.

However, one element that really stuck out for me - and one which I've been worried about since I got accepted to Medical School - is that most programs really care about showing a deep interest in their field.

On the face of it, that makes sense, but there's a bit of a dilemma at this stage, and it goes a bit like this:

Step 1: Acknowledge the need to show interest in the specialties I'm genuinely interested in.
Step 2: Realize I don't know exactly what specialties I'm genuinely interested in.
Step 3: Do some activities in specialties I think I'm genuinely interested in.
Step 4: Find out through those activities that I'm not actually as interested in some of those specialties as I initially thought.
Step 5: Panic, because now I've expressed interest in specialties that I might not actually want.
Step 6: Panic more, because I haven't expressed enough interest in specialties that may now be higher up on my preferred list of specialties to match to, but now have no time to do it.
Step 7: Weep softly in the fetal position.

The crux of the problem is that it's quite difficult to figure out what you want to match to and the most useful information on that front comes in Clerkship and Electives, when it's often too late to do anything significant to express interest in fields you haven't already, such as doing research within that specialty. Programs want commitment on students' part well before they commit to students and even before commitments can be realistically made.

Right now, I have a number of commitments and I think I can show some interest in every field I care about at this point - and I think I've managed to narrow it down pretty well. Yet, because I start some projects in fields that I'm not considering very highly anymore, I'm a bit constrained. I want to show deeper interest in the specialties I still care about, but have no time. Research is the big one - I've got two significant research projects on the go, but because they're not directly in the specialties I'm now looking at, I worry they may not count for as much as they could.

Yet, for all that doom-and-gloom, many residents I've spoken to have told me they really figured out their specialty in 3rd year. They all managed to match, so there's got to be a way. In 3rd year, once my preferences become a bit more clear, I'll have to start to go all-out for whatever specialty I settle on. I just hope that'll be enough.

Transitions

Hitting an interesting point in my pre-clerkship training right now.

We just finished two blocks that I really enjoyed, somewhat unexpectedly. MSK was great - I feel like I learned a lot, but never felt overwhelmed. I don't expect to go into a MSK-focused field like orthopedics or physiatry, so I didn't go into the course anticipating that I'd find it all that interesting, but I really did. Most of what I am looking at will involve some sort of MSK knowledge, so I'll take that as a win.

We also had a short Emergency Medicine block. I loved it. Every part of it. The underlying knowledge base I find fascinating, the clinical decision-making seems logically and useful, while its role in medicine intrigues me more than I thought it would. I'm now seriously considering emergency medicine as a specialty, after I had all but written it off.

Yet, we're now entering the final two blocks of my pre-clerkship training: Neurology and Psychiatry. I will not be a neurologist or psychiatrist. I do find some of these fields very interesting, but they're mixed with other aspects I find overly tedious. There's a lot of detail-oriented material with questionable relevance to clinical practice. These will be tough blocks to get through, especially with clerkship so close.

It's going to be a real challenge to stay focused on the classroom when all I want to do is get into the clinical setting. About all I can do at this point is to tell myself that I just need to get past these two final blocks and then the fun can start. Home stretch!

Stress Management

I took on too much this year. Not way too much, just a bit more than I should have, and at times it stretches me a bit thin. This causes some stress. Not a ton - I'm still staying on top of everything, I maintain some semblance of a social life and I do get to spend a fair bit of time at home with my significant other.

Stress management for me takes many forms, but the main one is just letting my brain sort through the dozens of thoughts in it. Sometimes this means some alone time, just bouncing ideas around. Sometimes this means discussing what's rattling around in my head with friends, family, colleagues, or even the dog (the dog is a very good listener when he's not stealing socks).

One of the main purposes of this blog is stress management. It lets me get those thoughts out without avoiding the world or overwhelming those around me. I find writing (well, typing) to be fairly relaxing as well. So, at times you'll see me writing about tiny, insignificant things that have little if anything to do with medicine. Sometimes I'll write diatribes about a very specific topic in health care. It all depends what's stuck up in my brain that needs to come out.

My hope is that between all these outpourings of random thoughts, there will be some useful bits for those reading, if there is anyone reading.