CaRMS Tour 2016

It's CaRMS tour time! There were tons of very well-dressed graduating medical students running around the hospital last week, getting tours, doing interviews, and meeting their potential future co-residents. A lot of them also looked terrified. Really terrified.

It was kind of interesting being a clerk on rotation during this time. I'm old enough (and look old enough) that many people don't immediately assume I'm a student. So when I've been running around this week, a few CaRMS interviewees have been extremely quick to jump out of my way. Not just polite-quick, but "I'm sorry if my presence offends you"-quick. I think some of them think I'm a resident and that they therefore need to be exceptionally nice to me during this time. It's a weird situation, since these people are all ahead of me in training and where I hope to be in a year.

I hope my CaRMS tour next year isn't as stressful at it seems from the outside!

Underpants Gnome Theory of Medical Education

One of the surprises for me in clerkship has been the unique nature of clinical training for physicians relative to that of other healthcare professionals. Before starting medical school, I trained and then briefly worked as one of these other healthcare professionals, receiving accreditation from my overseeing college and all that. My experience during my clinical training time was substantially different from what I've received in medical school.

The basic structure was similar - each week or so, I'd be assigned a preceptor who was working in the hospital, and I'd report to them for my training, pretty much the same as what happens in clerkship now. The difference was in our respective roles and the level of supervision. My preceptor had a job to do aside from training me. However, my job was essentially to do their job. If they had a task to do, I would try to do that task. The two of us basically shared my preceptor's job that they would normally do on their own.

Being inexperienced, I was obviously quite bad at things in the beginning - I was uncertain of what to do at times, horribly slow, and made a LOT of mistakes. Since what I was doing was still the ultimate responsibility of my preceptors, they kept a close eye on me and provided direct assistance when I started to stumble. As I gained more experience, the amount of support I needed declined and my preceptors started to get more comfortable with leaving me more of the job to do. They stopped watching me as closely and slowly gave me more and more independence. By the end, I was basically doing the work on my own, checking in with my preceptors only in exceptional circumstances. When I transitioned to working on my own, the shift in my responsibilities wasn't all that substantial - I was still relatively inexperienced and had a lot to learn to master my full role, but I had already been doing the bulk of the work for months beforehand, under almost the exact same constraints.

Most healthcare professions seem to work this way. A student nurse in clinical training works basically in a nursing role. A pharmacy student essentially acts like a pharmacist. They generally do the same tasks, have the same responsibilities, hold roughly the same hours, and are expected to have the same knowledge base.

Medical education, by contrast, does not follow this framework. There are distinct roles for medical students, residents (with further splits between junior and senior residents), fellows, and fully-licensed physicians. My roles, responsibilities, tasks, hours, and necessary knowledge diverge markedly from the residents, fellows, and physicians who serve as my clinical preceptors. Since my preceptors have different jobs to do than I do, I've found there's far less investment in whether or not I'm doing my job appropriately. They care about the results of whatever task I've been appointed, but more in the way a coworker cares about your performance than in the way a teacher cares about your performance. The ends seem to justify the means in medical education - it rarely matters how I do something in clerkship as long as it all looks alright in the end, and that leaves open a lot of room for mistakes to go unidentified or only caught after-the-fact.

The sharp divide in roles means competence in medical education is backward-looking rather than forward-looking. In my previous program, I had to be declared competent at the job I was going into before I was allowed to work without supervision. In medical education, everyone seems to move to the next step by demonstrating competence at their current role - student, junior resident, senior resident - rather than competence in their future roles, such as being an attending. Knowledge and skills develop at each step with some continuity, but functional knowledge for the future role isn't instilled, resulting in some very difficult and oftentimes unsuccessful transitions between roles.

The underlying premise of medical education is that exposure is a good enough teacher in itself. Yet, this is an Underpants Gnome approach to competency in medical education:

Phase 1: Exposure to clinical experiences.

Phase 2: ???

Phase 3: Competency!

There's quite a bit of evidence to suggest that our current system doesn't prepare learners well enough for the next step of their journey. There's the July Effect in teaching hospitals. Difficult transitions to clerkship, the first year of residency, or full practice are frequently reported.

Canadian residency programs are trying to adopt "Competency-Based Education" models, which appear to include a specific transition to practice component, and similar reforms are rumored to work their way down to the student level, but I'm skeptical about whether that's going to be a change in the fundamental approach at most programs or just a change in semantics. The division of roles between attending physicians, residents, and students is fairly well ingrained in the structure of academic medicine. Without a meshing of roles, it's hard to imagine medicine will move towards the models of other healthcare professions.

Temporary Optimism

I complain a lot about medicine and medical education on this blog. There's a lot about medicine and medical education to complain about. I've got a lot more to get out too, so don't expect that to change any time soon!

However, sometimes things turn out well and we actually do good work. I actually had a pretty good day today. I got to help some people in what I consider to be a meaningful way, where I got to use counselling and half-decent communication as much I suggested new investigations or medications. Plus, while I was running around trying to get everything done in time, I did manage to take enough time with each patient to do a good job, which has not often been the case (more on that later).

So colour me an optimist, if only for the day. Medicine is rife with serious, patient-harming problems, but if you keep an eye open for opportunities, sometimes those problems can be overcome or mitigated. Today had several of those opportunities, so it was a good day.

Likes and Dislikes in Oncology

I took a selective in Oncology, which comprised both Medical and Radiation Oncology. Cancer is common and terrifying, so it was good to dig into the disease a bit further. Continuing on my series of rotation take-aways, here are my thoughts on my rotation:

1) Conversations
Oncology isn't that heavy on the medicine side of things - the science behind treatments is complex and incredibly interesting, but the actual approach to treatment is fairly formulaic. Where there is a degree of complex decision-making is in considering a patient's preferences, as well as providing education and counselling. As someone who takes the most enjoyment from medicine when actually talking to patients and helping them work through their condition, I loved this aspect of the field.

2) Time
Oncologists have time. Time to talk with their patients. Time to consider their medical and social situations. Time to arrange long-term supports. Cancer is scary, so we treat cancer patients pretty well from what I've seen. Plenty of room for improvement still exists, but it is kind of amazing to see patients being given plenty of attention and resources, in stark contrast to the way some other maladies are treated.

3) Death
For understandable reasons, death is a pretty big topic in Oncology. Many patients die, and die quickly. Moreover, patients are aware of their impending mortality. It's an element that scares a lot of people away from the field, because, well, death is scary. I find I don't mind discussing death though. It's inevitable, and physicians can do a lot to manage life on the way to death. I'm of the view that physicians are not meant to stop death at all costs, but rather to facilitate the best life possible - that second goal is very achievable in terminal patients, and I derive a lot of satisfaction from that.

4) Double-Edged Sword
For patients not yet clearly on the palliative track, the challenge with cancer treatments is that they all have trade-offs. Surgery, radiation, and chemo can all have side-effects, some quite significant. We're getting better treatments that minimize the more debilitating risks, but each approach still involves a good measure of chance. More than death, this is the element of working in Oncology that gives me pause. No matter how well an Oncologist practices, they will cause their patients harm as a course of their treatments. Much of this is temporary and can be managed. Some of it is permanent and without recourse. Good communication of risks and benefits before starting treatment can at least prepare patients for these possibilities, but it's still quite a burden to accept that someone was injured because of the treatment plan you, as a physician, put in place.

5) The Happiness Test

With few exceptions, Oncology physicians seemed to be very happy people. They work with the most life-breaking diseases in the world, so I suppose it takes an optimistic person to stay in that field. Everyone was super nice, not just to the patients but to me as well. You definitely notice a difference when there are smiles on most people's faces, even as they're hard at work.

Communication

Errors in medicine are common. Really common. Like, shockingly, awfully common.

Luckily many of these errors result in no or minimal harm to patients, either because they're caught in time or because they're relatively minor mistakes. Yet, small errors could just as easily be big errors and small errors have a tendency to snowball, where a series of small errors results in big harm.

Most commonly, medical errors are due to poor communication. That is, everyone is acting as they think is appropriate, but they're missing information that would change their actions, information other persons have.

I'm on my CTU rotation now and it's striking to see how often communication errors occur in inpatient medicine. It's not just every day, it's every hour of every day, involving every patient who steps through the hospital doors.

Yet, the prevailing attitude seems to be that most communication errors are either expected, someone else's fault, or weren't actually errors at all. It's not a horribly surprising outcome, considering the system in most hospitals is not set up for effective or efficient transmission of information, there is little accountability for communication errors, and training in proper communication is practically non-existent. Heck, even training in the improper communication typical of inpatient hospital services is practically non-existent, being delivered "on the job" in bits and pieces, typically while a student or resident is already being given patient care responsibilities and having to figure out how to perform on the fly.

I knew communication was a big problem in medicine before I started medical school, one that contributed to sub-optimal patient comes. Nevertheless, being on the physician side of things has been disturbingly revealing. Communication errors are routine, pervasive, and we're nowhere close to fixing those issues. For the most part, I'm not even sure we're trying to fix them.

Medical School Interviews

In Ontario, interview invites are just now starting to come out. Obviously an exciting time for applicants and I wish everyone reading the best of luck if they're waiting to hear back about possible interviews!

It's the first year with the new MCAT in play, so for schools that put a decent amount of stock into the MCAT, this could be an interesting admissions cycle. The main question is how the CARS section will be evaluated with respect to the old VR. The previous MCAT supposedly had the same scale for all sections, but in practice the VR tended to have lower scores compared to the other sections, at least at the higher ends where medical schools place their cutoffs. A score of 13 in the Bio section was much more likely than a 13 on the VR. The new CARS section has supposedly fixed that discrepancy; a 130 should be as likely on the CARS as on the science sections. That's a positive change in the long-term, but it means some short-term chaos as applicants try to figure out exactly where they stand.

It's also my first opportunity to be involved in the application process. My school allows 3rd year students to be interviewers, though they tend to take 4th year students if they can. I've only signed up at this point and don't know if I'll be needed, but I hope to participate. I consider the admissions process to be the most important step in medical education and the student who interviewed me 3 years ago couldn't have been nicer or more fair. It would be great to pay that service forward. As someone with an interest in improving medical education, I think it would be a great learning opportunity for me as well.

Anyway, another best wishes for those waiting to hear back, and a huge congratulations to those who obtain an interview. It's the first step of many on the way to becoming a physician, but it's a huge step, one that deserves acknowledgement. I'll keep my fingers crossed to get to know a few of you during the interview days!

Electives - Classmates Edition

We're rounding towards the half-way point of third year, which means it's crunch time for specialty choice. At my school, our first real "deadline" for setting us on our paths is on Friday, when some of our home-school elective choices are due.

While I've been wrapped up a bit in my own approach to electives and specialty choice, it's been interesting to hear from my classmates, who are all going through the same thing. There are a lot of different strategies to choosing electives, as well as a number of thought processes to picking a desired specialty. If history is any guide, most (though not all) of these strategies will work. It's a helpful reminder that there's no one "right" approach to electives.

I'm also just interested in seeing where all my classmates end up. There's a pretty wide variety of personalities in the class, plus wildly divergent interests, but it's still a guessing game as to where any particular person will ultimately fit. It's definitely true that people change their minds in clerkship - while some people have been consistent, many more have switched their goals, some dramatically so. Even as we settle into the home stretch of choosing specialties, there's still room for change, and I'm finding the rationale behind those changes quite intriguing. Really wish I had a crystal ball to see how it all ends up for my class!