Monthly Archives: February 2010

Risk Averse

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Inspired by a post on Risk Taking and Failure written by a friend.

One of the most important skills everyone should learn is how to take risks. I’m not talking about foolish or rash decision making but of calculated and beneficial risks. For the most part, I credit a lot of my success to my willingness to take action in the face of uncertainty. Winning scholarships, getting job positions, finding opportunities, getting into medical school are all things I have benefited from taking good risks.

In many careers, calculated risk taking has many benefits. Business opportunities if coupled with entrepreneurial spirit and hard work can result in large financial gain. New artistic direction can be what separates you from the crowd. Having the courage to start a conversation with someone you don’t know may blossom into an important relationship. However, medicine often discourages risk taking, often to the point that erring on the side of caution is preferred.

Any risk will always have a chance of failure. You should only take risks if the odds are in your favor or if the reward far outweighs the cost. And that is exactly the problem in taking risks when it comes to medicine – the cost of failure is high.

A wrong mistake can lead to crippling disability.  An erroneous slip can lead to a malpractice lawsuit or a license suspension. One lab test missed or improper history can mean life or death. For example, even if the benefits of immediate treatment means a speedy recover, if a diagnosis is made and treatment started without confirming the diagnosis, the results may be disastrous.

That is why we are taught to be thorough in our history taking and physical examinations. That is why checking up on patients is so important, so that no alarm signs  slip go unmissed. That is why a differential diagnosis should be long and comprehensive, even if some items are highly unlikely. That is why extensive lab tests, imaging and consults are required. Don’t jump to conclusions. Be thorough even if it is going to cost you time and money. As a generalized rule, doctors err on the side of caution.

I think that is something I quite miss from my life before medical school. The chance to take risks and face the outcomes and consequences. I could aimed for all sorts of goals because I knew had the ability to rebound from my failures. I could push myself to my limits, be committed in several activities and try new endeavors. But now, I have a duty and a privilege to my future patients. To do well in my studies and become a good doctor. Instead of pursuing other interests, I have a job that I should do to the best of my abilities.

Perhaps I am over-exaggerating my situation to prove a point. It’s a bit like growing up. In yours twenties, you don’t have much to lose. If someone offered you one chance to win a million dollars on a 10:1 coin flip, would you take it? If you win, you get $1,000,000 but if you lose, you have to shell up $100,000. Mathematically, agreeing to the bet would be a no brainer. Now add twenty years to the same scenario, a house, a mortgage to pay, a car, a spouse, kids and bills that you are just scraping by with, your decision to take that bet drastically changes. If you win, a million dollars that could result in retirement but if you lose that money, how are you going to pay next month’s rent? Provide for your family? Would you still take that risk?

[I realize that the possibility of going into $100,000 of debt in your twenties is a great setback. You could even argue that when you're 40 and you have a stable job, you are more in a position to lose $100,000 than when you are just starting your career, but these numbers are just an arbitrary scenario and I hope you got the main point I was trying to make]

Possibility is traded away in return for stability. Predictable outcomes are favored when what you risk losing is  greater than the gain. When you become responsible for other people, especially in a job like medicine where a doctor-patient relationship is so important, I would feel really bad if I made a risky decision that negatively affected someone else.

So although risk-taking is a valuable trait to have, I often think being risk averse is also an equally important trait to have especially in medicine. Being paranoid and nit-picky, which is excessive at times, may one day save a life. Someone’s obsessive need for perfection or his insecure fear of failure can make a positive difference.

What are your thoughts on risk taking and risk aversion?

Canadian Medical Schools Prerequisites Summary

The single most effective thing you can do to improve your chances of getting into medical school is to  complete the right prerequisites. The more prerequisites you do, the more medical schools you will be eligible for and the greater your chances will be for an acceptance letter. Attached below is a table of all the Canadian schools and their prerequisites, including whether they require the MCAT and a degree. (Click on the picture to enlarge)

Click to enlarge

After looking at this table, you would see the most important courses to take would be are the following. Duration of each course may vary between schools, check the individual school websites for more complete information.

  1. Biology - 1 year
  2. General Chemistry – 1 year
  3. Organic Chemistry – 1 year
  4. Physics - 1 year
  5. Biochemistry – 0.5 year
  6. Social Sciences – 1 year

It is also in your best interest to take the MCAT as almost all schools require it. Surprisingly, only a handful of schools require you to complete a degree before starting medical school.

[Note] The courses do not have to be completed by the time you apply, they only have to be completed before you enroll into medical school. Eg. You can apply for medical school in September while taking Organic Chemistry and Biochemistry during that year.

Hopefully this will save you some time and help you plan your course selections. If you have any further questions, please leave a comment below and I will try to answer them all here.

No Better Time to Apply Then Now

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There was a recent New York Times article on the Surge in U.S. Medical Schools across the country.  If you’ve been following the trends, there has also been a surge in Canadian Medical Schools in the last few years and the government is pushing hard for new seats in the near future. Northern Ontario School of Medicine (NOSM) was created to help create more rural doctors. In the last 3-4 years, there has been roughly a 15% increase in seats across Canada. There is no better time to apply to medical school than now! With a current shortage of doctors, impeding retirement from up to 30% of current physicians and a booming aging population, Canada needs doctors now more than ever.

However, like the comments in the article pointed out, an increased amount of doctors is not the solution to rising costs and quality patient health. There is still a lack of doctors going into primary care like family medicine or pediatrics. Although the trend is changing according to globecampus.ca, still not enough medical graduates are choosing to become general practitioners.

I’m all for increasing medical school spots in Canada. Every year, I know many qualified applicants get rejected because there are not enough spots. Instead, these students end up going abroad to complete their medical training, a loss to Canada. Training and keeping our doctors here is vital to the success of Canadian health care. We shouldn’t have to keep relying on foreign doctors to fill in the gaps. Although we benefit from medical professional migration, we end up hurting the countries we take from. We need to create solutions to our own problems.

So if you are a student considering medicine in the next 5 years, now is as good as a chance as there will ever be for you to be accepted into medical school. Granted you will still need to have a competitive GPA, MCAT and extracurricular activities, the chances of you getting in has dramatically increased.

But if you do become a doctor, please consider primary care practice. What Canada really needs is not more doctors, but more of the right type of doctors. There will always be a role for specialists in the system but what we  really need now are more front-line doctors who can see patients before their problems escalate and help our population in the prevention of disease.

Choosing a Specialty

The major concern of most premedical students is whether or not they will be admitted to medical school. They fret over getting the best grades on their term papers, labs and exams. They often spend a summer studying for the MCAT while working in a research lab. They also volunteer on the side and remain committed to extracurricular activities they have picked up.

However, once students enter medical school their previous academic worries are replaced with the one question, “What kind of a doctor will I be?”

Failing out of medical school is an uncommon event. Most people who have made it this far will have developed the work ethics and study habits to pass. There are also staff and administration that will do their best to help you graduate, whether that be from financial difficulties or stress. Most schools have maternity leave policies and accommodate students taking a year off. Getting through medical school for the most part is straightforward. I believe the hard part is finding yourself amidst the medical culture that becomes all pervasive.

During your undergraduate studies, so much time is spent working towards being admitted into medical school that not much thought is given to what kind of a doctor you want to be. For one, it’s hard to truly understand the differences between all the specialties, especially if you have never had any exposure to them. Many students may think that surgery sounds cool and prestigious, but few know the grueling realities and lifestyles associated with it and likewise for the many other specialties of medicine.

In the first two preclinical years, medical students are exposed to the many areas of medicine in the classroom. They get snippets into the diseases and types of patients found in each but never a complete picture.

Now that I am coming to the end of my preclinical studies, I still feel as confused as ever as to which specialty I will end up choosing. It is always a concern that is lingering in my thoughts. What if I want to do a competitive specialty such as radiology, ophthalmology or plastics? Will I be too late to consider them because I have not done any research or networking in these fields? Or even the fields I think will be unlikely, such as psychiatry or OBGYN, how will I know if I actually don’t like them or not? Will lifestyle and pay be a factor in my final decision?

Hopefully, by next year I will have an answer or a rough idea. But take heed premedical students, your questions of What are my chances of getting into medical school will soon be replaced with What medical specialty should I choose? Your worries and concerns don’t fade away after entering medical school, it just becomes different. Every phase of life has its own challenges and rewards.

Below Average

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I was shocked when I realized my first medical school exam marks were below class average. And it still bothers to me when my class marks are below average. Medical school is humbling experience where half of the students,  all who excelled in their undergraduate degree, find themselves below average.

There is an old phrase that asks “what do you call the medical student who graduates last in his class?” The answer is still “doctor.” In a way, medical students regardless of their ranking in the class are still bright hardworking students. They have already been selected from the cream of the crop, what really is the difference between 99.0% and 99.5% percentile in comparison to the entire population? When you’ve been in the rat race for so long, it’s hard to forget about the rat race mentality. To compensate, many schools use only a pass/fail system for grading to avoid unnecessary stress and competition.

So is it reasonable for a person to be upset about receiving below average grades in medical school? For me, I use this feedback to find my weaknesses, as a reminder to not let my ego get the best of me, and as a way to challenge myself. After a while in medical school, you realize that your preclinical grades don’t really predict whether you’ll be a good doctor or not. Similarly, there are so many vital skills that are learned but aren’t tested, like history taking and physical examination skills that are essential in medicine. I’ve realized that I may not be the best at memorizing pathophysiology, biochemistry and clinical guidelines, but I have discovered I have a strong understanding and visualization of anatomy. I’ve realized I may not be able to explain detailed molecular mechanisms quickly and I often confuse drug mechanisms, but I can summarize complicated cases succinctly with all the main points.  You realize that you are below average in some areas and above average in others.

Through this whole journey, I’ve set my goal to be simple. Improve in my weak areas and minimize mistakes that can happen from them. Become better at recognizing places where I can err in and take action to prevent it from happening. Use my strengths to the best of my abilities and to compensate in my weaknesses. And in the process discover yourself and work on improving yourself.

Medical School – Working Hard but Rarely Bored

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Medicine can be pretty tough, but boring? There is always something interesting to see or learn.

Although I was busy during my undergraduate studies, I can still remember days or weeks where I would be bored with school. If I was particularly on top of my school work, I would often take the weekend off and do absolutely nothing productive and instead something fun. I would slack for weeks at a time and know that I could catch up. I remember studying for chemistry intensely until I knew the periodic table and each element’s properties down cold. There were tests where I could recite dozens of physic formulas without the need for a cheat sheet. I remember having to find extra work to do to challenge myself, get involved in clubs, and push myself to go beyond class expectations.

On the contrary, nowadays it seems like work always has a way finding me. It’s rare to have a spare moment just to read leisurely or contemplate about life’s big mysteries. There’s always more diseases to study, new terms to look up, clinical opportunities to be involved with. And I know as soon as clerkship starts and residency, it’s only going to get busier.

Medicine is challenging. Compounded with my initial dislike for rote memorization – though it has improved a lot – I often find learning everything overwhelming. When I peruse the titles on the library shelves, there seems to be a textbook for every imaginable disease possible, irregardless of how obscure they may be. There’s such a variety of subjects to learn, ranging from anatomy to epidemiology to each specific specialty. For a curious person like myself who likes to know everything about anything, I find it hard to have the same confidence of knowledge as I did in undergrad. Even for common conditions such as hypertension or diabetes, there is a wealth of knowledge out there that keeps changing.

I knew what I was signing up for when I decided to go to medical school. Long hours, grunt work and a whole lot to learn. It can get draining, mentally, emotionally and physically. There will be days where going to the washroom and taking a nice hot shower will become a luxury. Sleepless nights, angry patients, grieving families. Life long learning until the day you stop practicing.

There’s always something to do, something to learn, something to challenge you. It’s a trade-off I can live with.

The Difficult Patient

I was doing an ER shift today when I came across my first difficult patient. Mr. K was a 50 year old divorced man who came in irritably on a stretcher having passed out from COPD exacerbation. He was shaking all over and showed a distrust for the medical system: the paramedics that brought him in, the nurses, the entire system.

Nothing destroys a relationship with a patient faster than distrust and I realized it was going to be a tough situation as soon as I took his history. “Jesus ****ing Christ, Why are you asking me again! I’ve already told you guys ten times what my medical history is like! Just do what you need to do and get me out of here.”

It was uncomfortable, after discussing with my preceptor, to go ask more follow-up questions and do a physical exam. I felt defeated and flustered. What knowledge and competence I had about his condition evaporated once his bitter criticism hit me. For the most part, the limited patient encounters I had before were generally positive with them being encouraging and understanding that I was still a medical student. There’s always two sides to a coin.

After the shift while walking home, this difficult patient encounter lingered in my mind. I guess sooner or later, every medical student becomes a bit more cynical and pessimistic. Their young idealism and optimism is replaced with harsh reality, death and disease. And although I remain positive about medicine, there are hard lessons and growing pains to be experienced. Even though it is difficult, I will continue to respect and treat my patients with dignity, irregardless of religion, race, age, disease or attitude.

Medicine is interesting in this respect. It not only builds knowledge, but also character. You slowly begin to realize what kind of a person and eventually what kind of a doctor you will become with each patient encounter.  I hope I can become a doctor my patients trust.

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