Limited blogging recently and in the near future due to upcoming OSCE and exams. This is my last hurdle before clerkship, so the stakes a pretty high (in my mind, at least).
All I can say at this point is that I really, really, really hate when I have to spend more time learning for a test than learning for practice. OSCEs are great in theory, but I find I'm preparing as much for how they'll be testing me than what they'll be testing me on. There's some good reasons for this - the logistics of an OSCE are nightmarish - but it's still frustrating.
Tuesday, 26 May 2015
Wednesday, 13 May 2015
Match Statistics - 2015
I like numbers. Comes from a background in math, I suppose.
So when the yearly match statistics from CaRMS come out, I get a little more excited than a normal person probably should, even someone who's future may be influenced by those numbers.
Each year, there are surprises in the match stats. Many of these are one-time anomalies, quirks that reverse themselves the year after. Some, however, continue trends or herald the start of new ones. This year had a few surprises which may turn into longer-run trends. Here were the ones I found most interesting.
1) Psychiatry got more competitive - while it expanded.
We need more psychiatrists. And we need them in low-service areas (psychiatrists in well-served areas tend to see very few patients). Mental health is just too important to continue in its current, underserviced state. This year match rates to Psych dropped, despite a moderate expansion of residency positions. Far from a one-time change, this seems to reflect a multi-year trend, albeit with a greater-than-expected change this year. From conversations with classmates, I can see Psych remaining more competitive than in past years.
The reasons for this increase in competitiveness are probably multi-faceted, but I think the big ones are jobs, work hours, and the overall growth of the field. Right now, only a few specialties have a good job market. Psych is one of them. Few specialties have low working hours. Psych is also one of them, depending on individual circumstances. Psych is also evolving quickly as a field, with meaningful advances in diagnostics and management of many psychiatric conditions, and more advancements on the way.
Psych still has a very challenging patient population and the pay is on the low end for physicians. It's encouraging to see that despite these downsides, the field's popularity is growing
2) Some surgical specialties not all that competitive this year.
If Psych was the surprise competitive specialty, Orthopedic Surgery, Neurosurgery and Urology were the surprise uncompetitive specialties, at least by surgery standards. And that's with a slight reduction in the number of residency spots for these specialties.
The reasons for this change likely parallel those for Psych - bad job market (especially in Neurosurg) combined with horrendous working hours (especially in Neurosurg). These are still surgical specialties so they've retained some popularity, but specialties should take note: students are not overly eager to struggle through a brutal residency without a reasonable payoff at the end.
3) What happened in Public Health?
I have little to say here - Public Health is a small field when it comes to residency positions, but clearly is in demand. Virtually half those who wanted a Public Health program failed to match to it.
There aren't too many specialties I have to research before commenting on, but I had to do some reading on Public Health as a specialty. After doing so, I'm still baffled. Public Health is a vitally important subject, but I have no idea why it would require an MD or a separate residency (as opposed to a Master's) to participate in. That makes its popularity confusing to me. If a person really wanted to work in public health, why not do a PhD in the field instead of an MD? If they wanted clinical practice plus a hand in public health, why not something like a Family Medicine residency + a Master's? An MD with a specialization in Public Health appears to lack the deeper training of the first route and similarly lacks the clinical acumen of the second, while taking longer to complete than either.
I feel like I'm missing something and would greatly appreciate being filled in on where I've gone wrong. It's very hard for me to tell why a specialty is so popular when I'm still figuring out why it exists at all.
Thursday, 7 May 2015
Stories of Olde
Old stories or legends are interesting beasts. They contain oddities and contradictions that baffle us, sometimes making us judge our forebears for their silly or antiquated ideas.
Here's the thing - I (and millions of other people) just watched Avengers: Age of Ultron this past week, and it's hard not to draw parallels between the stories we care about today and the ones of centuries past. It's a pretty ridiculous story, containing elements of both reality and fantasy, just like the older fables. It draws on characters that have been around for decades and have changed significantly in that time - Thor, the Hulk and Iron Man were all created in the early 60's, Captain America's been around since the 40's. Heck, even the super-villain Ultron, a robot, was created in the late 60's and has undergone several re-imaginings.
On the DC-side of things, Superman and Batman have gone through dozens of different iterations since they were introduced in the late 30's. Hundreds of years later, when historians are sifting through our cultural legacy, they'll see a lot about these superheros. It's hard to see how they won't be treated as significant aspects of our lives - there's just too much about them out there, over too long a period of time, for them to be considered minor elements. I can see people in 2500 getting confused about the details of what we believed about these characters, just as we get confused about the details of some past legends from forgotten civilizations.
Not sure where I'm going with this, just a random thought, but it's fun to try to see our world the way we tend to view the world of the past.
Editing
I edit for the school's journal. It's a fun, generally rewarding experience. I get to read about fun topics in medicine - some familiar, some completely new to me - and I get to see the level of expertise in academic writing of my classmates. I also write for the journal, which is equally fun. I've gotten to write about some really interesting parts of medicine and hone my own writing skills.
I really encourage anyone in medicine (or considering medicine) to get involved with writing on an academic or professional level, and student journals are a perfect medium. They're just rigorous enough to push students a bit further, out of their comfort zone, without the frankly onerous restrictions involved in, say, publishing in a more standard peer-reviewed journal. All instances of academic or professional writing provide a chance to explore concepts and organize thoughts in a way simply studying topics can't.
I don't consider myself to be an overly strong medical student, but I do pride myself on the ability to discuss a wide variety of topics in medicine with little or no preparation. Doing things like academic writing is part of that - I feel I can engage in discussions because I've had many of them already, often with myself while writing articles (or, at times, blog posts like this).
The flip side is that both writing and editing are a LOT of work. I'm currently sitting with a stack of articles on my lap, awaiting my notes. There are some highly interesting pieces to read through on my pile, but each one is hours worth of work. Nothing to do but get to them!
I really encourage anyone in medicine (or considering medicine) to get involved with writing on an academic or professional level, and student journals are a perfect medium. They're just rigorous enough to push students a bit further, out of their comfort zone, without the frankly onerous restrictions involved in, say, publishing in a more standard peer-reviewed journal. All instances of academic or professional writing provide a chance to explore concepts and organize thoughts in a way simply studying topics can't.
I don't consider myself to be an overly strong medical student, but I do pride myself on the ability to discuss a wide variety of topics in medicine with little or no preparation. Doing things like academic writing is part of that - I feel I can engage in discussions because I've had many of them already, often with myself while writing articles (or, at times, blog posts like this).
The flip side is that both writing and editing are a LOT of work. I'm currently sitting with a stack of articles on my lap, awaiting my notes. There are some highly interesting pieces to read through on my pile, but each one is hours worth of work. Nothing to do but get to them!
Sunday, 3 May 2015
Drinking the KoolAid
Complementary and alternative medicine gets brought up a lot at my school, usually not in an overly positive manner.
There's reason for that animosity. Every physician has a story of a patient that had a less-than-ideal outcome because they opted for care that either diminished the effectiveness of conventional medicine or replaced it entirely. In some instances, deaths have occurred. When there are people promoting and even profiting of those outcomes, it's hard not to get angry.
When you listen to the people providing these alternative medicine services, however, they believe strongly that they're helping. Many of these practitioners go through extensive training before they practice, training which reinforced the theories underlying their practice. When you're told over and over again that something is right, and most of the people you interact with believe in it as well, it's hard to accept or even contemplate that it might be wrong. So, these alternative medicine practitioners continue to believe they're helping in spite of contradictory evidence because it's simply inconceivable that that contradictory evidence could be right. They drank the KoolAid.
Here's the thing - every field has their own KoolAid, including medicine. For those who like to go back to the evidence, some of the KoolAid is easy to point out. There are many procedures or approaches in medicine that lack supporting evidence or have even been shown to be ineffective. Yet they are still a part of our practice. Traditional medicine does tend to be more responsive to evidence - clearly unhelpful procedures do work their way out of the system, over time, but it takes far longer than it should. I have had physicians, in front of a full class of medical students, discuss a procedure, admit that the available evidence shows that it works no better than a placebo, and then insist that it still has a role in medicine.
More importantly, there are certainly some things that we're doing that are ineffective or unhelpful and we have no idea that they are ineffective or unhelpful.
Complementary and alternative medicine should be scrutinized, but so should conventional medicine. I think conventional medicine holds up much better under that scrutiny - that's why I'm getting an MD and not an ND - but we should always be willing to hold conventional medicine to the higher standards we'd like to see applied to complementary and alternative medical practices.
There's reason for that animosity. Every physician has a story of a patient that had a less-than-ideal outcome because they opted for care that either diminished the effectiveness of conventional medicine or replaced it entirely. In some instances, deaths have occurred. When there are people promoting and even profiting of those outcomes, it's hard not to get angry.
When you listen to the people providing these alternative medicine services, however, they believe strongly that they're helping. Many of these practitioners go through extensive training before they practice, training which reinforced the theories underlying their practice. When you're told over and over again that something is right, and most of the people you interact with believe in it as well, it's hard to accept or even contemplate that it might be wrong. So, these alternative medicine practitioners continue to believe they're helping in spite of contradictory evidence because it's simply inconceivable that that contradictory evidence could be right. They drank the KoolAid.
Here's the thing - every field has their own KoolAid, including medicine. For those who like to go back to the evidence, some of the KoolAid is easy to point out. There are many procedures or approaches in medicine that lack supporting evidence or have even been shown to be ineffective. Yet they are still a part of our practice. Traditional medicine does tend to be more responsive to evidence - clearly unhelpful procedures do work their way out of the system, over time, but it takes far longer than it should. I have had physicians, in front of a full class of medical students, discuss a procedure, admit that the available evidence shows that it works no better than a placebo, and then insist that it still has a role in medicine.
More importantly, there are certainly some things that we're doing that are ineffective or unhelpful and we have no idea that they are ineffective or unhelpful.
Complementary and alternative medicine should be scrutinized, but so should conventional medicine. I think conventional medicine holds up much better under that scrutiny - that's why I'm getting an MD and not an ND - but we should always be willing to hold conventional medicine to the higher standards we'd like to see applied to complementary and alternative medical practices.
Monday, 27 April 2015
What Should Medical School Admissions Look Like? (Part II)
In Part I, I wrote about the some more conceptual changes in how I believe medical school admissions could be improved. Here I'll give an outline for an admissions process I'd like to see. It won't be perfect - there are certainly important aspects I may have overlooked or addressed poorly - but it's an attempt. I welcome any criticisms or suggestions.
Introduction
I would still want to look at many of the same things current admissions committees look at, namely:
Introduction
I would still want to look at many of the same things current admissions committees look at, namely:
- Undergraduate marks
- MCAT
- Extra-curriculars
- Letters of Reference
- Essays
- Interviews
What differs is how I would use these factors. All these factorss are proxies for the attributes we actually want in physicians - intelligence, work ethic, empathy, communication skills, etc. They're imperfect proxies, but they have some overlap. I think admissions processes should capitalize on that overlap to better get at the underlying attributes rather than treating the proxies as sufficient measures alone.
Step 1: Is this person academically intelligent enough?
An applicant passes this stage if:
- They have alright marks and a very strong MCAT (~75% and 12/11/12 minimum)
- They have very high marks and a mediocre MCAT (~90% and 8/8/8 minimum)
- They have good marks and a good MCAT (~80% and 10/10/10 minimum)
Rationale: The idea here is to capture a lot of people with the intellect necessary to be physicians. The numbers can be played with a bit depending on the applicant pool, Not trying to get the smartest people here, just a good number who are all likely to be smart enough.
Step 2: Does this person have a strong enough work ethic?
An applicant passes this stage if:
- They have stellar marks (~90% minimum) and ECs that show some productivity outside of their curriculum
- They have good marks (~80% minimum) and ECs that show a plenty of productivity outside of their curriculum
- They have alright marks (~75% minimum) and ECs that show extensive productivity outside of their curriculum
Rationale: We want hard-working physicians, whether they're working hard at school or hard outside of school. In evaluating ECs at this stage, the focus should be on the quantity of hours worked, not necessarily the quality (though effort involved should play a factor). Anything and everything should count here - jobs of any sort (including fast food or retail), child-rearing, taking care of family members - literally anything. Medical school admissions don't give enough credit to people who are struggling just to keep life going and thereby give preference to those who are fortunate enough not to have that struggle - this step could help to level the playing field, even slightly.
Step 3: Has this person explored the medical field?
An applicant passes this stage if:
- They have any schooling or ECs with direct exposure to medicine, health care, or individuals with medical conditions
- They have any personal experiences with the medical system, either from their own medical conditions or those of loved ones
Rationale: Very easy to pass this step - just a quick check to make sure applicants have actually investigated medicine as a career. Being a physician should be an active choice, not a default position.
Step 4: Does this person work well with others?
An applicant passes this stage if:
- Their LOR has no red flags
Rationale: Again, an easy step to pass. Anything above a dismal or indifferent LOR will be fine. The main challenge with LORs is having people who know the applicant well enough to vouch for their competency. That's an important skill in itself, especially in the relationship-dependent field of medicine.
Step 5: Does this person bring something to the field of medicine?
An applicant passes this stage if:
- Their ECs and essays demonstrate a good average degree of achievement and skill-development in the 7 CanMEDS roles, with achievement above a certain level in at least 5 of the 7 roles.
Rationale: Here's where the quality and diversity of ECs factors in. Ideally we want physicians who are strong in all the CanMEDS competencies, but that's unrealistic for individuals just starting their career. Being good - but not great - at all aspects is a reasonable place to start. So is being incredible in a select few, as long as there is at least some development in most of the other competencies. The main goal here is to cut out the one-trick ponies who might be amazing in one way, but sorely lacking in the other aspects. Not everyone who would make a good physician is going to be a great scholar, or a great manager, or a great collaborator. Yet, individuals with no experience in scholarly activity, no experience managing others, and no experience collaborating are going to be in trouble, even if they happen to be superb health advocates and experienced communicators. This is intended to be the main EC cut-off.
Step 6: Can this person communicate?
An applicant passes this stage if:
- Their interview scores (MMI scores ideally) are in the top three quaters of those invited to interview
Rationale: Interviews suck. They're high stress and often fairly subjective. Unfortunately, so is medicine, so interviews have value. This is especially true in the margins, either in the very high end or very low end. The idea here is to eliminate the low end. I prefer the MMI to allow for increased, independent sampling of applicants' interview ability (though some MMI questions are just plain weird).
Step 7: Putting it all together
This is the final step. An applicant passes this stage if:
- Their combined score from all aspects of their application is high enough to be granted an invitation for admissions
Rationale: A final rating is necessary in just about any large-scale application scheme, so here it is. I picture the combined score comprising 50% of the interview score and 10% for each of the following: essays, ECs (evaluated for work ethic as was done in Step 2), ECs again (evaluated for achievement as was done in Step 5), undergraduate marks, and combined MCAT score. It's all a bit arbitrary at this point, but the idea is that the truly deficient are already out by this stage, so the specific metric shouldn't matter all that much. I put the additional emphasis on interview scores because intelligence is almost never lacking in medical students, but the same can't always be said about communication skills.
Conclusion
Again, I won't claim that the system I've presented is perfect. In many ways, it's quite similar to what many schools do now, maybe just a bit more complex in some respects. The main differences I'd like to emphasize are flexibility in academic requirements as well as an overall increase in the number of applicants passing the initial cutoffs and receiving interview invites. This would undoubtedly be an expensive, labour-intensive system. That's by design, but it's not a small consideration.
Would this be a better approach? I have absolutely no idea! If anyone has an opinion on this, please comment. I've treated this mostly as a mental exercise. What do I care about when looking at future colleagues and what would I like medical school to look at? Ultimately, my process above reflects my priorities: I want to see a greater emphasis on work ethic, communication skills and diversity of experiences than currently seems to exist, with perhaps a somewhat lower emphasis on raw intellect. Individuals with different priorities would undoubtedly design a system with an emphasis on different qualities. Nevertheless, I enjoy discussions about what it means to be a good physician, and I can think of no better way to focus that discussion than on the topic of medical school admissions, where the physicians of the future are chosen.
- They have alright marks (~75% minimum) and ECs that show extensive productivity outside of their curriculum
Rationale: We want hard-working physicians, whether they're working hard at school or hard outside of school. In evaluating ECs at this stage, the focus should be on the quantity of hours worked, not necessarily the quality (though effort involved should play a factor). Anything and everything should count here - jobs of any sort (including fast food or retail), child-rearing, taking care of family members - literally anything. Medical school admissions don't give enough credit to people who are struggling just to keep life going and thereby give preference to those who are fortunate enough not to have that struggle - this step could help to level the playing field, even slightly.
Step 3: Has this person explored the medical field?
An applicant passes this stage if:
- They have any schooling or ECs with direct exposure to medicine, health care, or individuals with medical conditions
- They have any personal experiences with the medical system, either from their own medical conditions or those of loved ones
Rationale: Very easy to pass this step - just a quick check to make sure applicants have actually investigated medicine as a career. Being a physician should be an active choice, not a default position.
Step 4: Does this person work well with others?
An applicant passes this stage if:
- Their LOR has no red flags
Rationale: Again, an easy step to pass. Anything above a dismal or indifferent LOR will be fine. The main challenge with LORs is having people who know the applicant well enough to vouch for their competency. That's an important skill in itself, especially in the relationship-dependent field of medicine.
Step 5: Does this person bring something to the field of medicine?
An applicant passes this stage if:
- Their ECs and essays demonstrate a good average degree of achievement and skill-development in the 7 CanMEDS roles, with achievement above a certain level in at least 5 of the 7 roles.
Rationale: Here's where the quality and diversity of ECs factors in. Ideally we want physicians who are strong in all the CanMEDS competencies, but that's unrealistic for individuals just starting their career. Being good - but not great - at all aspects is a reasonable place to start. So is being incredible in a select few, as long as there is at least some development in most of the other competencies. The main goal here is to cut out the one-trick ponies who might be amazing in one way, but sorely lacking in the other aspects. Not everyone who would make a good physician is going to be a great scholar, or a great manager, or a great collaborator. Yet, individuals with no experience in scholarly activity, no experience managing others, and no experience collaborating are going to be in trouble, even if they happen to be superb health advocates and experienced communicators. This is intended to be the main EC cut-off.
Step 6: Can this person communicate?
An applicant passes this stage if:
- Their interview scores (MMI scores ideally) are in the top three quaters of those invited to interview
Rationale: Interviews suck. They're high stress and often fairly subjective. Unfortunately, so is medicine, so interviews have value. This is especially true in the margins, either in the very high end or very low end. The idea here is to eliminate the low end. I prefer the MMI to allow for increased, independent sampling of applicants' interview ability (though some MMI questions are just plain weird).
Step 7: Putting it all together
This is the final step. An applicant passes this stage if:
- Their combined score from all aspects of their application is high enough to be granted an invitation for admissions
Rationale: A final rating is necessary in just about any large-scale application scheme, so here it is. I picture the combined score comprising 50% of the interview score and 10% for each of the following: essays, ECs (evaluated for work ethic as was done in Step 2), ECs again (evaluated for achievement as was done in Step 5), undergraduate marks, and combined MCAT score. It's all a bit arbitrary at this point, but the idea is that the truly deficient are already out by this stage, so the specific metric shouldn't matter all that much. I put the additional emphasis on interview scores because intelligence is almost never lacking in medical students, but the same can't always be said about communication skills.
Conclusion
Again, I won't claim that the system I've presented is perfect. In many ways, it's quite similar to what many schools do now, maybe just a bit more complex in some respects. The main differences I'd like to emphasize are flexibility in academic requirements as well as an overall increase in the number of applicants passing the initial cutoffs and receiving interview invites. This would undoubtedly be an expensive, labour-intensive system. That's by design, but it's not a small consideration.
Would this be a better approach? I have absolutely no idea! If anyone has an opinion on this, please comment. I've treated this mostly as a mental exercise. What do I care about when looking at future colleagues and what would I like medical school to look at? Ultimately, my process above reflects my priorities: I want to see a greater emphasis on work ethic, communication skills and diversity of experiences than currently seems to exist, with perhaps a somewhat lower emphasis on raw intellect. Individuals with different priorities would undoubtedly design a system with an emphasis on different qualities. Nevertheless, I enjoy discussions about what it means to be a good physician, and I can think of no better way to focus that discussion than on the topic of medical school admissions, where the physicians of the future are chosen.
Back Up Plans
Whenever I advise someone considering medical school on how they should be preparing, I almost always tell them to explore alternative careers and to have a back-up plan in mind that they could easily pursue.
I do this for three distinct, but related reasons.
1) Medical school admissions are competitive and unpredictable
Except for a few super-human applicants who have perfect GPAs, amazing MCAT scores, stellar ECs, and an amazing interview approach, no one has a guarantee of acceptance to medical school. Many individuals still have a very good chance of admissions, so the idea of having a back-up isn't a way of saying that the person isn't cut out to be a physician.
Hope for the best, plan for the worst. If you've got an interesting back-up career plan in mind, the worst ends up not being too bad. That brings me to my next point...
2) Medicine isn't the only good career out there
I like medicine as a vocation. That's why I'm pursuing it. But medicine is hardly a uniquely good profession.
Some aspiring future physicians focus in on medicine without bothering to consider the alternatives. These alternatives might actually be more enjoyable, fulfilling careers for some people. They're worth checking out!
Every career has its pros and cons. Medicine is no different. Knowing what else is out there helps provide perspective on why medicine is actually worth pursuing - and maybe, why it might not be.
3) Developing a back-up makes students better medical school applicants - and better physicians
Applicants who are clearly well-positioned to pursue another career often make better applicants. Their ECs are typically unique and show skill development. They have meaningful experiences to discuss in their essays and interviews.
Basically, it's clear they bring something to the table that other applicants won't. When these individuals start in medical school, residency, or practice, that time spent developing a back-up career isn't lost, it's applied to the field of medicine. One way medicine's great is that it's a very diverse field with many opportunities to draw on virtually any area of expertise. Having some additional, unique expertise going into medicine only helps - it's much harder to get that after getting admitted to medical school than it is beforehand!
For the most part, I tell people to explore alternative careers not because they can't or shouldn't become physicians, but because I think it's beneficial no matter what the outcome. It's helpful if a student doesn't get into medical school, if they choose not to go to medical school, or if they get in. To me it's a win-win-win.
I do this for three distinct, but related reasons.
1) Medical school admissions are competitive and unpredictable
Except for a few super-human applicants who have perfect GPAs, amazing MCAT scores, stellar ECs, and an amazing interview approach, no one has a guarantee of acceptance to medical school. Many individuals still have a very good chance of admissions, so the idea of having a back-up isn't a way of saying that the person isn't cut out to be a physician.
Hope for the best, plan for the worst. If you've got an interesting back-up career plan in mind, the worst ends up not being too bad. That brings me to my next point...
2) Medicine isn't the only good career out there
I like medicine as a vocation. That's why I'm pursuing it. But medicine is hardly a uniquely good profession.
Some aspiring future physicians focus in on medicine without bothering to consider the alternatives. These alternatives might actually be more enjoyable, fulfilling careers for some people. They're worth checking out!
Every career has its pros and cons. Medicine is no different. Knowing what else is out there helps provide perspective on why medicine is actually worth pursuing - and maybe, why it might not be.
3) Developing a back-up makes students better medical school applicants - and better physicians
Applicants who are clearly well-positioned to pursue another career often make better applicants. Their ECs are typically unique and show skill development. They have meaningful experiences to discuss in their essays and interviews.
Basically, it's clear they bring something to the table that other applicants won't. When these individuals start in medical school, residency, or practice, that time spent developing a back-up career isn't lost, it's applied to the field of medicine. One way medicine's great is that it's a very diverse field with many opportunities to draw on virtually any area of expertise. Having some additional, unique expertise going into medicine only helps - it's much harder to get that after getting admitted to medical school than it is beforehand!
For the most part, I tell people to explore alternative careers not because they can't or shouldn't become physicians, but because I think it's beneficial no matter what the outcome. It's helpful if a student doesn't get into medical school, if they choose not to go to medical school, or if they get in. To me it's a win-win-win.
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