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

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

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

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

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

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

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

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

Comments on the Match

With the match now over and my class now aware of their results, we've had a bit of time to decompress and look ahead to residency preparations. On that latter point, there is a lot to get done - forms to fill out, organizations to sign-up with, some certifications to arrange, figuring out how to get paid (but yay, money!).

While I know where most of my class is headed now, it's all been through voluntary disclosures, which means I pretty much only know about my classmates who are happy with their results (and all the classmates I'm closer to all matched). Seems like my school had a pretty good year, but I know I'm only getting a partial picture. We do get a debrief on the school's overall match results soon, so I'll know more then. Here's hoping my class did as well as I think they did, and those who didn't match are getting enough support for the next steps.

I wanted to comment quickly on the only match stats we have at this time - the list of spots left unfilled from the 1st iteration. Interpretation of these is always a bit hazardous, as these positions mix both the CMG and IMG unfilled positions together. You can make some inferences, but there's naturally a bit of guesswork.

Some of the results aren't terribly surprising. There's a handful of positions left in the smaller, more technical fields with poorer job prospects. There's a few positions in typically competitive fields (like Derm) that are most likely IMG spots that were intentionally left unfilled. And there's the crush of positions in Quebec that go habitually unfilled as Quebec oversupplies its residency positions.

Some of the results aren't exactly shocking, but are notable. Internal filled almost every spot. Internal did see a jump in competitiveness last year, and the word is that trend continued in a big way this year. While this data doesn't confirm that perception on its own, it's certainly consistent with it. In the other direction, Psychiatry had a few more unfilled spots than I expected, given that it is also garnering a bit more attention. Psychiatry has been steadily gaining positions, however, and the remaining spots are generally in more remote locations - ironically, the places that are probably lacking the psychiatrists those extra positions were meant to train.

Lastly, Family Medicine had an absolute ton of unfilled spots this year. Family usually has a number, but the proportion of Family spots left open is greater than it has been in the recent past. Interest in Family, which took a bit of a dip last year, may be a bit low this year as well. That would fit with the notion that Internal has jumped in popularity - while overall competitiveness for CMGs in CaRMS has increased somewhat, Internal is a huge specialty and for it to become more competitive means other larger specialties have to get less competitive. It makes sense that a rise in interest in Internal would be coupled with a drop in interest in Family. We'll have to see when the full match stats eventually come out.

Matched

Quick update because I'm still processing the result - successfully matched today in Family Medicine to my top-choice program. Whew.

It's a huge sigh of relief, but I know it means that the real work is only just beginning. I now have a ticking clock of two short years to get myself practice-ready. It all feels very real now, but I'm pretty excited knowing that this is where the stakes get higher. Onwards and upwards and all that!

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.

Considering a Career in Medicine - SCIENCE!

We focus a lot on how students can prove they're good enough for medicine. These posts are for students wondering if medicine is good enough for them.

Short Version: Medicine absolutely requires a solid understanding of scientific principles and facts, as well as an ability to critically analyze new scientific studies or discoveries. The common undergraduate precursors to a career in medicine are based in scientific study, for good reason. Scientific research is intimately connected to medicine, and involvement in research can be beneficial to a prospective physicians' career goals before, during, and after medical school. An interest in science is therefore a common reason why students choose to pursue medicine.

Medicine is an inherently applied field, however - when it comes to the nuts and bolts of scientific discovery, the basic or fundamental research that underlies much of humanity's technological progress, physicians rarely get involved. Rather, physicians involved in research tend to spend most of their time on clinical research, which investigates potential applications of discoveries others have made. This can be an advantage or a disadvantage, depending on individual preferences. Science-loving potential medical students should give some thought to how they want to incorporate scientific knowledge into their careers and ensure that being a physician will satisfy that objective.

Long Version: Modern medicine could not exist without the development of the scientific method and its continual application to new realms of human knowledge. To the extent physicians' interventions are effective in preventing death or improving life, it is thanks to the works of physicians and scientists in the past and present. As such, it is impossible for a capable physician to exist without a solid understanding of both prior scientific discoveries as well as the process that leads to new scientific discoveries.

Furthermore, the pathway to become a physician, with some uncommon exceptions, requires a solid scientific background. Medical school admissions has moved away from requiring certain degrees or pre-requisite courses, but most still require the science-heavy MCAT and the vast majority of medical students do their undergraduate education in science, math, social sciences, or engineering. Put simply, the pathway to medicine runs through science and therefore medicine attracts those with a proclivity towards scientific study.

Part of the path to medicine for many students includes becoming actively involved in scientific research. Research is by no means required for admissions to any medical school in Canada, but it can certainly help with the admissions process at the majority of schools. Even at schools that do not consider research in their admissions process, or do not weigh it heavily, many matriculants will have significant research experience. There continues to be some value to engaging in research after admissions. Many residency programs will take research experience into account. This is usually as a secondary consideration to clinical performance, however, and research is really only required for a few highly-competitive fields. Once in residency, most programs will have required research projects, and research productivity can be important for landing positions after residency, depending on specialty and desired location of employment.

Yet, despite its close ties to the study and advancement of scientific knowledge, medicine is far more concerned with application of new discoveries than in their production. Physicians are largely involved with what is termed "clinical research" as opposed to foundational research or basic sciences research. To oversimplify somewhat, clinical research involves study on humans. For ethical reasons, we tend not to allow such research without having some expectation as to what will happen, so clinical research generally involves relying heavily on knowledge derived from basic sciences research, typically performed by non-physicians. This is not to diminish the difficulty or importance of clinical research, which is fraught with challenges and is critical to developing truly evidence-based medical practice. However, it does speak to the place of physicians within the process of developing new approaches to medicine - if a useful new intervention in medicine takes 100 steps to become discovered, developed, optimized, and proven effective, physicians involved in research are usually responsible for the last couple steps only, with an emphasis on optimization and proving efficacy rather than on discovery or development.

To many, this limited role of physicians in the scientific process is not a drawback. Many physicians have no desire to be involved in research at all, even those enthralled by the miracles of science. Medicine is vast and learning how properly apply the ocean of scientific information relevant to one's practice can be plenty of mental stimulation for science-minded individuals. Similarly, for those interested in advancing medical knowledge but are uninterested in the basic sciences research students typically encounter in their undergraduate studies, clinical research can be an ideal way to satisfy that objective.

At this point, the growing demographic of clinician-scientists deserves recognition. Clinician-scientists are physicians who have additional training towards becoming capable researchers, usually through intensive graduate work. In some cases, the focus remains on clinical research, with clinician-scientists doing much the same research that an academic physician without additional training would undertake, but with perhaps a bit more expertise and often with a greater proportion of time spent on research activities rather than on clinical duties. Other clinician-scientists, however, will try to straddle the divide between clinical and basic sciences research. Translational research, with its emphasis on taking or making new scientific discoveries and bringing them into clinical practice, is receiving substantial attention in academic circles. Clinician-scientists, with focused training in basic sciences research, are considered ideally placed to take advantage of these opportunities.

The number of these clinician-scientists is fairly small, however, and not without reason. Becoming established as both a clinician and basic sciences researcher requires a substantial amount of time. A physician typically does not enter independent practice until their early 30's, and the same can be said for most basic sciences researchers. To manage a career in both areas can easily require a person to train into their late 30's or early 40's before independence in medical practice and research are achieved. That additional time spent training means losing significant financial opportunities, that extended training delays entry into employment. Additionally, research tends to pay less than clinical work, meaning clinician-scientists often earn less than their clinician-only counterparts.

Additionally, not all who pursue clinician-scientist training take advantage of both their intended roles. Many individuals who obtain both an MD and a PhD, whether that PhD was obtained before, during, or after medical school, do no research or research that could easily be accomplished with an MD alone. Likewise, there is a small group of clinician-scientists who no longer work with patients in a clinical setting, or who have minimal clinical duties, effectively working off their PhD alone. Obtaining both an MD and PhD can be an attractive prospect for highly ambitious students, but should be approached with caution and with as full an understanding of the clinician-scientist role as possible.

To summarize, medicine absolute involves scientific knowledge and benefits from those interested in science. Being interested in science is a good reason to consider medicine! Yet, potential medical students must keep in mind that an MD prepares students to be clinicians first and researchers second, with a focus on clinical research only. A physician's use of scientific knowledge is usually confined to direct applications for patients. For those who would strongly prefer to do research outside of a clinical setting, or those who have minimal interest in working with patients, an MD may not be the best fit, and those students would likely be better served in a PhD-only program. For those who truly want to do both, the clinician-scientist route, which usually involves completion of both an MD and a PhD, may be worthwhile. Science-lovers should take the time to check out all their options before diving into a career in medicine that may or may not be tailored to their specific interests.

Pets and Private Health Care

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

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

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

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

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

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

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

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

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

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

Research and Other Extra-Curriculars

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

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

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

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

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

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