Pre-Call

Creative Commons – dskley

You would think being on call for the last two and a half years would make this easier, a little more tolerable. Especially after doing 1 in 4 nights for the last six months, I should be used to it. Yet here I am again, getting this sense of anxiety the night before my call shift. This is my pre-call dread.

This pre-call dread gives me a sense of impending doom, as if my call day will be the worst day of my life. I get worried, I get keyed up, I complain in protest of not wanting to be on call. People often talk about their post-call days and how wonderful they are. Few people talk about pre-call.

I’ve spoken to my colleagues about this phenomenon and they agree it’s a real thing. It manifests itself differently for each person. Some people get fatigued more easily and decide to sleep earlier in preparation for their call day. Others distract themselves by doing something fun like watching a movie or having a nice dinner. For me, I don’t sleep very well when I’m pre-call. Instead, I often get a last minute ambition to tackle the multiple undone items on my to-do-list as a final effort to delay the inevitable.

The silly thing is I don’t even find call that bad. When I’m on call, time goes by quite quickly, I learn a lot and I enjoy the independent decision making. Most nights, I get enough rest so that my post-call days are decently productive. I’ve learned to cope with being on call well so it’s bearable. Pre-call on the other hand, I handle poorly. I feel uneasy. I feel tension.

So here I am again, the night before I’m on call, trying to tidy up all the unfinished tasks from the week. My room’s usually in disarray, my bags are not packed and I don’t want to go to bed. I’m writing a post about this dread. I feel anxious and I’m usually not anxious about anything. Presentations, projects and exams don’t even cause the same sense of distress for me as pre-call.

It’s a strange feeling. I guess people with generalized anxiety must feel this way all the time. I sympathize for them.

But alas, my time’s up. My pre-call day is over! On to the real call and then that blessed post-call day. Such is the life of a resident.

Deciding on a CaRMS Residency Rank List

I have been chatting with some friends who are going through CaRMS residency match. They’ve finished interviewing at various programs and now they are in the process of coming up with a Rank List. In short, your rank list is the order of programs where you would like to do your residency. However, where you ultimately end up is decided by a match algorithm. In many ways, applying for a residency program can be more daunting than applying to medical school.

First there’s the uncertainty of where you might end up. When you apply to medical school, you at least have a choice a which school you would like to attend when you receive your acceptances. For the residency match, you are instead “matched” and that’s the end of the discussion. There’s no backing out of it, you are legally contracted to your residency program once you have been matched.

Secondly, for applicants who have not made up their minds on what specialty they would like to pursue, the rank list can be a difficult to finalize. They may have interviewed for two or three specialties and now face the difficult decision on choosing a career, even if they haven’t quite made up their mind yet. At least when there was a rotating intern year in the 90’s, graduates had more time and exposure to help them make that decision.  Now-a-days, if you want to do a competitive specialty (derm, ophtho, ENT), you almost have to know even before your clinical years to be competitive.

Coming up with a Rank List can be difficult task. But it doesn’t have to be.

Deciding on a Specialty

For those who have applied to more than one specialty, figuring out which specialty you want to do is the first step. I’ve written about my thought process in choosing a specialty before (Part 1, Part 2), it’s a topic I frequently talk about on this blog, and there are a lot of good resources available to help you out. Here’s one I reviewed on The Successful Match. (Amazon)

Hopefully, if you’ve been thinking about this throughout medical school – figuring out what type of medicine you want to do won’t be too hard.

If you are just starting medical school, I highly recommend writing down your thoughts on specialties on a regular basis. I made a shortlist of programs I was interested in after Year 1, Year 2, and Year 3. During clerkship, take some time to reflect on each rotation you go through and write down what you like and dislike about each specialty. As you can see, my initial impressions changed quite a bit by the time I had to apply to residency.

If you really can’t decide on a specialty, you can take some solace in knowing you can switch programs even during residency. It’s uncommon but definitely doable and I know people who have done so successfully.

Deciding on a Location

Apart from specialty (easy for those who are only applying to one), the next biggest factor is deciding where you want to do your residency. There are so many things that make location such a big deal. Family members, significant others, children, outside-work commitments. Picking up and relocating your life should be taken seriously. I honestly believe choosing where you will be doing residency has such a large influence on your personal wellness during your post-graduate years.

If you’re settled down, have deep-ties to a city and foreseeable see yourself living there for a long time, it would be crazy to consider doing residency anywhere else. On the flipside, there are applicants who have spent their entire education and life in one city and want to experience something different. Residency is a perfect time to try someplace new. Residency eventually ends and if you do want to come back to your hometown or Alma mater, the diversity of experience you will have is often viewed favorably.

Factors to consider when deciding on location

  • Urban vs Rural
  • Large city or small city
  • Family, Partners, Children, Friends
  • Commitments outside of clinical medicine – research, volunteer, church, etc.

Ranking Specialty or Location?

In some instances, especially for competitive specialties, people are left to decide whether the should weight specialty or location more important.

In general, I would choose specialty over location. Although location is an important factor, it is the more flexible of the two options. After residency, you are more than welcome to move to your preferred location. The same can’t be said for specialty. There’s no guarantee you can change specialty after you match. Furthermore, specialty choices influences how you will practice medicine for the rest of your career. Residency on the other hand eventually ends and if it means toughing it for a few years, it’s bearable.

Understanding the Algorithm – Rank What You Want

If you read the official CaRMS website, there’s no secret to the matching process. You don’t have to worry about how programs rank you. The process is always weighted favorably for applicants. Applicants should rank programs in order of preference.

You can be sure a lot of thought has been put into this algorithm. In fact, the 2012 Nobel Prize in Economics was awarded to Lloyd Shapley and Alvin Roth for their work on market design and matching theory. Shapley and Roth were personally involved in designing the algorithm that they use in residency matching, and since it’s implementation in 1997, residency matching is as fair as it can be. This algorithm also applies to couples ranking.

I won’t go into the mathematical aspects of the algorithm, you can read more about the matching algorithm and the NRMP (US Match) on the Nobel Prize Page (pdf). It’s pretty cool math.

Never Rank a Program You Do Not Want to Attend

Because the CaRMS match is finalized, you should never rank a program that would not want to attend. because if a program is on your list, there is a chance that you could match there. Some people say it’s better to go unmatched than to match to a place you don’t want to go to, I’m still undecided about this. Being unmatched puts you in a difficult spot, it’s a mark on your record that can be hard to overcome. My advice to people is to apply broadly during the CaRMS process so you have options to choose from. Remember that practically everybody gets their top choices. Only a few percentage of applicants run into trouble and those are usually with competitive specialties.

Other Factors to Consider when Making a Rank List

There are many other things to consider when picking programs. After specialty and location, I would say these things shouldn’t be weighted as much. Remember that every accredited program will give you good training, and how good of a physician you will become depends more on what you do than the program you attend. Here’s a list of other things to think about

  • Faculty/Mentorship relations
  • Resident happiness, collegiality
  • Opportunities for fellowship, research, jobs
  • Funding for well being, projects, conferences

Making a List, Checking It Twice

When you finally come up with an order that you are happy with, sleep on it and check it again later. If you are still pretty content with your list – check it once more to ensure the order is correct and submit it. Whether you decide a week before or minutes before the deadline doesn’t make a difference to the final result. Submitting it as soon as you’re ready gives you a peace of mind. At that point, you would have done everything on your part and the rest is out of your hands.

Trusting Your Gut, Choosing Happiness

My final advice would be to trust your heart and gut in choosing a residency program. There are a lot of intangible elements that can’t be easily entered into a a pros and cons list. Talk to people who are important to you to see what their input is. Don’t get caught up with other applicants and their ranking strategies. Find what works for you. It all works out in the end for the majority of people, so there’s no need to stress out. Ultimately, choose the place where you will be the happiest. Even if you a program is very prestigious but you are miserable, it can make residency a very tough few years. You’ll be a trained adequately as a doctor wherever you go. You might as well be happy.

Taking Ownership of Your Patients

In many ways, residency is not too different clerkship. You rotate through different specialties, you try to learn how to take care of patients from your teachers. Sometimes, I feel like I knew more medical knowledge when I was a medical student than I do now. During clerkship, I saw fewer patients, read more and spent a lot of time in my studies. As a resident, educational activities take a second seat to clinical duties, often consists of a lot of scut work.

However, the biggest difference you face as a resident is the responsibilities  you are given and how you handle them.

I remember in medical school I had several preceptors tell me to “take ownership of your patients.” At the time, I thought this meant I should see my patients daily, know their medical history inside out, have all their lab work and investigations checked obsessively and write comprehensive daily notes. To me, taking ownership was knowing everything about my patients..

But looking back now after being a resident for half a year, I think taking ownership is more than just good patient care, it’s a philosophy where you learn to be the most responsible person to your patients.

Last week’s NEJM had an excellent perspective on medical hierarchy and how when we don’t take responsibility and ownership, patients get harmed.

We realize that, each of us unsure, we gained confidence from the perceived assurance and expertise of the other. We unearth the other specialists who participated in the patient’s care. The oncologist had wanted the infected effusion drained so he could safely commence chemotherapy. The respiratory physician had recommended referral to a larger center for drainage. The infectious diseases physician had no more antibiotics to offer. The general internist bowed to the others, and the surgeon was approached as the next service provider in line. Tragically, no one person looked beyond the effusion to the whole patient. Although he saw myriad specialists in his last week of life, he died lacking holistic care.

It’s hard to really understand this concept until you are on your own, on call in the middle of the night looking after sick patients. As a medical student, you were always supervised either by your resident or attending. Whenever patients got sick or there was some obstacle, there was always someone you could defer to.

To me now, taking ownership means assuming you are the most responsible physician looking after this patient. Although as a resident I am still supervised by a staff doctor, I think having this mentality of being the most responsible person will ultimately make me a better doctor and provide better patient care. It means not assuming that other people will order proper investigations or check lab results. It means advocating on behalf of your patients. It means doing that DRE that everybody has avoided doing or taking extra time to talk with family members.

However, assuming responsibility comes with a cost. It can be emotionally draining. You become invested in your patients. You experience their joys but also their sorrows. You end up working more and your efforts are not always appreciated.

And as I head into the second half of my intern year, finding this balance between being your patient’s doctor and personal wellness will be a continued challenge. But Residency is exciting. If medical school was learning how to be a doctor, residency will determine what kind of a doctor you will become.

CaRMS Tour – Finding the Right Fit

http://www.flickr.com/photos/caribb/3896931071/To all the final year medical students around the country, I wish you all safe travels and great memories during your residency interview tour.

Recently, I was talking to a few students who were going through the process. There is always a lot of stress and anxiety involved – What should I wear? Will the interviewer like me? Will I match at all?? I was nervous before my interviews too.

Looking back, I was fortunate I found the whole process quite stress free and dare I say fun. It was the perfect chance to see cities all across Canada, think about how far I had come and ponder about where I would end up.

There is one thing I wanted to share from my experience, it’s that “The CaRMS tour is as much interviewing programs and finding the right fit for you, as it is the other way around.

People are often so worried about schools liking them that they don’t take the opportunity to find out which schools they like. An activity that helped was after each interview, I would take 10 minutes to write down what I thought about each program. Some questions I would answer were

  • What did I think about the city? Could I be happy living here?
  • What do I like about this program, what impressed me the most?
  • What did I not like about this program, what there anything that concerned me?
  • What was my impression of the residents, the program director?
  • Will matching here be the best for my career goals? Personal life?
  • How would important people in my life react to me matching here?
  • Could I see myself living here long term? Would it just be for residency?

This simple exercise was very powerful in two ways. The first was it actually made each subsequent interview easier. With each reflection, my interview answers were more articulated and sincere. I could better compare the program I was interviewing for with the ones I had already done, and I believe I was a better applicant for it.

Secondly, it made ranking the different programs much easier. Ranking your programs is perhaps the last stressful milestone in medical school. If you are not prepared for it, it can be overwhelming. But if you take the time to critically evaluate the schools when you visit them and create a general impression, you will have a pretty good rank list at the end of your interviews.

So to everyone currently going through the residency match process – enjoy the process. Keep in mind that these interviews run both ways, and you have the responsibility of interviewing each program too.