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Everything posted by ralk

  1. Hmm, good stats there, that's very helpful. So, there would seem to be a real benefit if this were implemented nation-wide. Wonder what the breakdown would be province-by-province though. When I looked at last year's numbers, it seemed as though there were about as many Ontario IMG spots left as there were IMGs matching to Ontario in the 2nd round (17 each). IMGs also gained some of that ground in less desirable locations (such as NOSM, which had no IMG spots left in the 2nd round but matched 4 IMGs), meaning CMGs correspondingly likely took some more desirably-located IMG spots that they now won't have access to.
  2. That's a bit of a surprising move. Considering how tight the ratio of spots to graduates is for CMGs in Ontario, not sure why the provincial government would want to lock in that ratio moving into the second round. There's no great stats on crossover of CMGs and IMGs to spots originally designated for the other stream, but from what numbers are available, I'd guess that it's close to even (that is, about as many CMGs end up in IMG spots as IMGs end up in CMG spots). This should mean the net effect on match rates should be zero or at least fairly small, but it makes the system less flexible and I'm not sure I see an obvious upside. Programs now have a smaller pool of candidates to draw on for both CMG and IMG spots, meaning they're not going to get the optimal candidate as often. Hopefully there's a bigger plan here - it would be an interesting approach if more CMG spots were added, for example - but in a vacuum I see this change as introducing a few (relatively small) problems while solving none.
  3. To make sure you're getting good financial advice, do some research before and/or after any financial meetings and check what you know against what they say. If it's not lining up, go somewhere else. Financial advisors - whatever their official capacity - will know things you don't, but should always be able to explain their recommendations in a way that makes sense to you. If they can't, they either don't understand the system (or your situation) well enough to give more than the basic information they're comfortable with, or they're selling a product/approach/idea that benefits them or their company more than it benefits you. In that first case, they might still be giving good final recommendations and you might have some wrong ideas, but if they can't work you through the gaps or misunderstandings in your knowledge, they shouldn't be trusted to direct your money. Don't need to know everything about financial matters - that's why you go through and pay experts in the first place - but need to know enough to ask meaningful questions, and to detect BS answers when they come.
  4. Have to agree with this. Rural ERs often function more like well-supplied and well-staffed walk-in clinics than they do as true ERs. Most don't have the equipment necessary to do full resuscitation (and the physicians covering them may lack the necessary skills in the first place), so these get sent along to larger hospitals anyway. Many don't have the volume to justify full 24 hour coverage either - if they only need a single physician covering during the day, then night-time shifts are necessarily going to involve a lot of down-time for the one physician on at night. Sure, it's nice to have a 24 hour walk-in available closer by for semi-urgent issues, but it's not particularly efficient use of resources, particularly in areas with limited healthcare resources in particular. Concentration of personnel and equipment into fewer, larger centres, would be better in some cases. Get some real ER docs in there rather than FPs without dedicated ER training running the show, ensure adequate ER equipment availability, and increase the supply of supportive diagnostic services for longer hours. Turn the remaining ERs into what they are, essentially limited urgent care facilities, for daytime/evening hours. Yes, that means some patients have to travel further to get to the closest ER, but it means that they might have less distance to go to get to an ER that actually functions like an ER - not a place without any lab services, diagnostic imaging, the ability to intubate, or even an awake physician.
  5. Residency programs are not allowed to ask about any medical conditions, including mental health issues. If any were to ask, the best course of action is generally to lie and deny any conditions, then report the program for violating CaRMS rules. According to current rules, your diagnosis should have no direct bearing on your ability to match to a residency program of your choosing. Licensing is a bit of a different issue in that most provincial colleges require a disclosure of any conditions which has or could reasonably affect ability to practice competently. This is fairly vague and the line isn't well-specified, so this sort of disclosure would depend very much on your personal situation. Mental health conditions that are outside the typical anxiety/depression would, in my opinion, generally require disclosure, but it's impossible to say without more details (which you absolutely should not provide on a public forum). If in doubt, this would be a good question for your psychiatrist. Such disclosures can cause some headaches, mostly as regulating authorities may require compliance with certain steps to ensure any risks to patients are minimized, but are necessary if your condition could impact patient care in a significant way. For the most part, health conditions should not impact an overall ability to practice medicine, though could impact what you practice and how you go about things. Someone missing a hand cannot be a surgeon, for example, but could likely make a fine psychiatrist. Likewise, someone with a history of addictions issues might require frequent checks on medication stores if they were to work as something like an anesthesiologist, with easy access to highly-addictive substances. If you've made it through medical school successfully, regulatory bodies generally won't prevent anyone from practicing. People are generally told to avoid mental health diagnoses, not just because of possible disclosure to regulatory bodies, but also for insurance purposes. You have to disclose any diagnoses for insurance, and that can be costly, or leave you open to gaps in your insurance for at least a certain period of time. However, this "do not get diagnosed" mantra should really only apply to mild conditions that do not necessarily require medical intervention to address effectively, and mostly because of the insurance effects - anything serious enough to require disclosure to a provincial college should absolutely get diagnosed and treated, because at that point it is a danger not just to the practitioner but their patients as well. If you've already been diagnosed, then there's not much point stressing about it - disclose when legally required, do not disclose when not legally required, and adhere to any treatment plans required to ensure safety when treating patients, if any are necessary at all.
  6. Keep in mind that while the tax is decently high, it's the same as it would be for anyone making $230k, in or out of medicine. Student loans are a lot, but with our interest rates, it's a fairly manageable sum. Even as a resident, with a far lower salary and take-home, I've made a solid dent in my overall debt load. The main advantage to medicine is that these earnings are pretty much guaranteed, and start at a young age, while other career paths only earn these sorts of numbers if you're top of your field, significantly older, or both. Even in FM, being a physician is a pretty lucrative career and high earnings mean high income tax, no matter how you get there. The high tax burden is the reason to take full advantage of those tax credits though - no one should be paying anything close to that $85k figure in income tax if they're making responsible financial decisions (and maybe giving a bit to charity ) Tuition credits are a huge benefit, but don't factor too much into staff income. Most residents run out of credits somewhere in the middle of their R3 year, so an FM doc will run out of those credits pretty early into their first year of practice, assuming they didn't do a +1 year. As an R2, I basically pay zero income tax, which is a major benefit when it comes to paying down debt and moving away from the (cheaper) student life, so even if it doesn't impact my future income as a staff, these credits make a big difference to my overall financial situation and quality of life.
  7. Owning a clinic vs working for a clinic doesn't change your tax burden in any way. Owning a clinic means you are in charge of your own overhead, whereas working for a clinic owned by others usually involves some sort of arrangement for the clinic to cover your overhead for you, typically by taking a share of your billings. You get taxed on whatever is left after overhead either way. If you're a particularly good manager of your own clinic, you might be able to pay less overhead than if you worked for a clinic you don't own, but any savings are likely to be very small. Physicians can save money on taxes in various ways by incorporating, but this can be done without owning your own clinic. The net earnings pre-tax are unchanged, while the amount saved in tax is going to be variable and depends on what corporate taxation laws are taken advantage of, and how. Using the $230k figure as an example, taxes would take about $85k in Ontario (which is about middle-of-the-pack in taxation rate). Various deductions available to everyone - such as charitable donations, RRSP, childcare or medical expenses - can reduce this a fair bit on their own. RRSP contributions alone can reduce overall tax burden by at least $10k per year. Holding money in a corporation can allow for income deferment, which over time could reduce the overall tax burden somewhat. Income splitting with a spouse or child is also a fairly common practice to reduce overall tax burden, but is almost certainly being phased out by the current federal government. In any case, none of this has anything to do with owning - or not owning - the clinic where an FP works.
  8. It's tricky, as most of the fields that have large numbers of Saudi residents are not ones in particularly high demand in the Canadian system. In some cases, Saudi trainees were taking the place of CMG spots that were intentionally (and in many cases justifiably) rolled back in favour of spots in other, more in-demand fields (like FM, for example). With a few exceptions (possibly IM), I doubt the answer to this loss of residents/fellows will be more CMG spots. Rather, I think we'll see other internationally-sponsored residents be recruited to fill those spots if possible, or we'll have to see resident call demands adjusted in these programs to account for these lost residents. In the short term, existing residents in these programs will likely see their call adjusted to the allowed maximum, with staff having to cover any holes. To the extent that we see new CMG spots, it should and likely will be in fields with comparatively few Saudi residents, such as FM, EM, or Psych.
  9. ralk

    Running in elections while applying

    1) Very hard to say. There's plenty of room in any admissions process for bias and a public figure will always be subject to more pre-conceived notions than others. This could hurt, help, or have a negligible impact. Any provincial election will involve taking (or dodging) some potential controversial positions, especially if this is being done in conjunction with a party. Even if you say nothing, you're linked to the rest of your party, and it's pretty much guaranteed one of them will say something controversial to at least some of the population, including some physicians, no matter what political stripe you run as. Overall, I can see a lot more potential to hurt your applications than to help them. 2) Long deferrals are generally not given by most schools, though I have heard of rare examples of extended deferrals (usually on a year-by-year basis) for very good reasons. I doubt any school would give you 4 years credit right off the bat - at best, it would likely be a year-to-year decision where they could rescind your acceptance at any time. Besides, if you are elected, would you not be planning to run again as an incumbent? Being a politician is rarely a one-and-one thing, especially for younger candidates. In any case, both medicine and public office such total-life commitments that, at least initially, it's probably best to choose a path and commit to it wholeheartedly than try to do both at the same time. You're far more likely to do both poorly than either well if you're splitting your focus. It's certainly possible to maintain an interest in the other field (ie be a politician who has a focus on healthcare, or a physician who is active politically), and once established in either field, it's very possible to switch into the other, but trying to do both at once seems like a recipe for disaster.
  10. Seen some rumblings on social media saying some have been instructed to leave by the end of August. Nothing official though from the Saudi end. The Canadian federal government doesn't seem interested in kicking any students or residents out, so it's all driven by Saudi Arabia's timelines.
  11. Well, Yemen might not be the best example here, seeing as Saudi Arabia is a major reason as to why that country is so volatile these days...
  12. We'll see if they carry through with this threat. It would be more disruptive for them and their citizens than it would be for us, so it seems like a very strong reaction for how this situation started. If they do go through with it, the effect on our system will likely be mixed, though probably negative in the short term. Call and duty schedules could go very crazy, especially in some programs with many of these learners. Some residents may unexpectedly find themselves working extra call shifts, particularly in the short term when there isn't as much time to plan around these disruptions. Programs and hospitals also get a fair bit of money from Saudi Arabia for this training and that could see some very real reverberations through the medical education system, resulting in some cuts to certain voluntary hospital- or program-provided perks. Smaller, less competitive fields that rely heavily on these learners will likely see the greatest changes. Over the long term, there could be some benefits. This could open up capacity in some programs to take on new residents, as despite programs' protestations to the contrary, foreign-sponsored students do take up learning opportunities that could be directly elsewhere, especially with the new pressure to open up additional CMG spots. From a quality perspective, while Saudi-sponsored trainees had a wide range of capabilities (as with any larger group of individuals), I generally have found them to be on the below-average end of the spectrum when it comes to residents of equivalent training levels, at least in a Canadian practice setting. On the balance of things, I imagine programs and hospitals will view this as a decided negative - after all, they took on these learners for a reason. The healthcare system overall will probably see changes closer to neutral once the dust has settled. For other residents, I'd argue there will be short term pain, but some rather modest benefits over time in the way of less crowded clinical teaching centres. One element I came across that I believe may be a negative from a broader perspective is that these residents spent years, typically half a decade or more, immersed in Canadian culture. Their kids - and most have kids - grew up around Canadian children. That imparts certain values which are hard to shake, even when they return to Saudi Arabia. Saudi Arabia is, if only very tentatively, starting to make some moves towards a more progressive, open society, and the more people who see the benefits that come with a more Canadian mindset, the faster such changes might happen. Medical residents from Saudi Arabia are universally from a more privileged class than the vast majority of the country, and in many ways have directly or indirectly profited from the oppression of wide swathes of their citizens, but as most successful revolutions - peaceful or otherwise - only occur with the support of at least part of the privileged classes, the more individuals in that echelon of society open to reform, the better the prospects for reform get. Sounds like most of these students and residents will be transferred to other western nations, so it's likely they get the same general exposure to more liberal societies. Still, the chaos of this announcement could lead to some missed opportunities to inch Saudi culture closer to the west, and reduce the frequency of events like the one that started this whole diplomatic row.
  13. ralk

    CaRMS statistics

    Yep, those stats are available here. There's definitely diminishing returns on program rankings, as about half of people match to their #1 choice program and after about the 5th ranked program, candidates are more likely to go unmatched than go matched to a lower ranked program. That said, if you're not getting one of your top 5 programs, those lower ranked programs suddenly matter a lot because they can reduce the chance of going unmatched significantly. What I tend to tell students is to apply as broadly as they can, but then not to sweat it too much if they've got fewer interviews than expected. Once CaRMS comes around you can't do anything about the number of interviews you received anyway, and it only takes a relatively small number of interviews to get close to the "optimized" chances at matching.
  14. Have you seen the tattoos some old people have?! It'll be a good conversation starter for a lot of them. Yeah, there might be a few who don't fit perfectly with your personality including with how you appear, but every physician has patients like that, who aren't a perfect fit for whatever reason, but for whom a good relationship with can still be developed. That you're aware of the possible perception is important, as you may have to adjust your conduct for more traditionally-minded patients, but that's a very small challenge to overcome.
  15. As long as the tattoos themselves are not offensive and you're generally presentable in dress and decorum, don't think most people in medicine would care much about tattoos, even large ones. Facial tattoos or obvious neck tattoos might be the exception there, just because they can be distracting and aren't anywhere near as common as tattoos elsewhere, but I can't see anyone objecting to something a sleeve of flowers and waves. Plenty of physicians have tattoos, even ones that are visible in their day-to-day work.
  16. Match rate's below 90%. These days I'd call pretty much every specialty besides FM and a few smaller unique specialties moderately competitive or worse.
  17. Didn't see that the CaRMS stats were out until now, a few weeks after the fact, but wanted to get a competitiveness breakdown out there, particularly given the difficulties experienced with this year's match. I've attached the full data set, but wanted to highlight the larger specialties directly here as well as offer a few comments. As always, my preferred metric for competitiveness is the percentage of individuals who rank a specialty first overall who match to that specialty. Those matching to an alternative discipline are also listed, as it provides a sense of how easy it is to back-up to another specialty when shooting for a particular first choice specialty. This metric is not a perfect representation of competitiveness, nor is it the only one available, but given available stats I believe it has the most value to those approaching the match and deciding on their CaRMS strategies. All stats are for the 1st iteration and for CMGs only. First Choice Discipline Percent Matching to Discipline Percent Match to Alternative Discipline Percent Unmatched Family Medicine 96.4% 1.0% 2.6% Internal Medicine 88.9% 9.1% 1.9% Diagnostic Radiology 88.9% 6.2% 4.9% Psychiatry 85.8% 9.0% 5.3% Anatomical Pathology 84.2% 7.9% 7.9% Physical Medicine & Rehabilitation 83.9% 12.9% 3.2% Orthopedic Surgery 80.4% 3.6% 16.1% Radiation Oncology 77.8% 14.8% 7.4% Pediatrics 77.6% 19.9% 2.6% Neurology 76.4% 16.4% 7.3% Neurosurgery 69.2% 11.5% 19.2% Anesthesiology 68.5% 21.2% 10.3% General Surgery 63.6% 10.8% 25.6% Obstetrics and Gynecology 63.4% 28.6% 8.0% Urology 58.3% 25.0% 16.7% Ophthalmology 52.1% 29.6% 18.3% Emergency Medicine 50.4% 37.4% 12.2% Otolaryngology 47.2% 22.6% 30.2% Dermatology 43.3% 48.3% 8.3% Plastic Surgery 34.6% 23.1% 42.3% A few thoughts on these numbers: 1) Across the board, a competitive year for surgical disciplines. These specialties have slowly been losing residency spots due to their generally poor job markets, but demand seems to have largely stayed put despite this, driving competition up. With over a quarter of people applying to Gen Sx, ENT, and Plastics going outright unmatched in the first round, and over 15% in pretty much all other surgical disciplines speaks to the risks involved going down that career path. To be a surgeon these days, you've got to really want it, and fight for your spot. 2) By contrast, certain moderate and high competitiveness specialties can be rather safe with an appropriate back-up plan. Derm and OBGYN have overall combined match rates (first choice + alternative) close to the weighted average of all specialties. More people who picked Derm first ended up in a back-up specialty than in Derm itself, a figure fairly consistent with previous years. Part of this may be driven by those with weak interest in the field - say a person who is essentially going for FM but taking a long-shot on a Derm program on the off-chance it works out - but considering that obtaining a Derm interview in the first place isn't a guarantee, I think there's something to be taken away by those specific numbers. 3) Likewise, two specialties this year had a combined match rate better than FM, generally considered the safe specialty to apply to - namely, IM and Peds. Here I do think individual circumstances play a role that prevents a simple interpretation of these numbers, as those who pick FM first tend to apply less broadly than those going for specialties, and most of those backing up from IM and Peds will end up in FM. Still, there was a growing inclination that Peds and increasingly IM were competitive enough that you had to gun for them like you would a surgical specialty, ignoring a back-up entirely, and I don't think that's true at all. Back-ups remain viable, especially in these specialties, if approached correctly. 4) Rads continues on the pathway towards non-competitiveness, a journey it's been on in fits and spurts for half a decade now. As someone who gave Rads a good hard look in pre-clerkship without ever really coming around to the field, I'd be very interested in exploring what's driving this trend. My guess is a combination of increasing work requirements, slowly declining incomes (though still exceptionally high, even by doctor standards), and a growing medical student preference for patient contact are the main drivers, but even that seems like it's missing something. 5) As was already apparent, this was a rough match overall. Too many left without a residency position after the first round and as is now being exposed, medical schools and provincial governments had no real plan to address this. Now that the dust has settled, the last-minute efforts to provide emergency residency spots in Ontario, plus the military opening up additional spots after the match, have helped improve the immediate crisis. Yet, the underlying math of the situation has yet to really change. As we approach the time when the final residency numbers get set, here's hoping some more wiggle room enters the system. While the vast majority of graduating CMGs will have a good outcome, even if nothing changes, that bad outcomes for a small subset are now virtually assured is very concerning. For all those reading, please remember that unmatched CMGs are more than ever victims of circumstance and should not automatically be considered weaker or flawed candidates. One mildly frustrating change with the reported stats this year is that CaRMS has not provided the numbers for people who match to a given specialty when it is not their first choice. That makes it harder to identify specialties that are good options to back-up into, though I strongly suspect this continues to be FM and IM. Lastly, a few caveats on the data above. First, this works off of first choice rankings, which are not always straight-forward. Some individuals will put a single program in one specialty followed by a ton in a second. Some will want a particular specialty but get no interviews and be left with only their back-up options to rank first. Many will apply in a limited geographic area, or generally utilize a bad match strategy which results in them going unmatched for reasons that have little to do with their chosen specialty's competitiveness. Second, while I have listed all specialties in the excel spreadsheet attached, please interpret the smaller ones with caution. Lots of variability in these specialties year-to-year that make definitive conclusions almost impossible. Finally, some specialties have chosen to offer streams with slight differences from the standard program - such as those with an academic or research focus - that appear as a completely separate CaRMS discipline in the stats. This makes interpretation of these specialties much more complex, as these slightly different streams undoubtedly share the main applicant pool as their main streams. This means if someone wants, say, a Clinician Investigator Program as their first choice but would be perfectly happy with just the normal stream, if they end up matching to that normal stream, they're automatically shown as falling into a "second choice" program, even when they really didn't. This is particularly bothersome for the Public Health programs, which are split between "Public Health and Preventive Medicine" and "Public Health and Preventive Medicine including Family Medicine", but are essentially the same specialty. Same could be said of the lab-based programs, which are shades of the same thing under different names. There's not nearly enough transparency in residency matching and these shenanigans make what little data we have even worse. If I've gotten anything wrong with the numbers, please let me know and I'll correct it ASAP. I try to double-check things but something can always slip through and sometimes the source material gets things wrong too. CaRMS stats 2018 First Round.xlsx
  18. Absolutely. Being geography-constrained and going for competitive specialties still means a risky match overall, but by focusing heavily on only a few programs (especially if it's at the home school), it opens up some back-up options that might not be as feasible when applying cross-country for the 1st choice specialty.
  19. Quick update - when I first made this post, CaRMS data on specialties that applicants back up into was essentially missed. CaRMS has since updated the numbers, so I think a quick dig into those is worthwhile. About 360 people backed up into a specialty - that is, they matched to a specialty that wasn't the one they ranked the highest. Over those, 290 backed up into either FM (228 applicants) or IM (62 applicants). Another handful backed up into the larger, moderately competitive specialties (11 to Psych, 10 to Peds), with scattered numbers elsewhere. The highly competitive specialties like Derm essentially have no one backing up into them, as could be expected. Split specialties that are essentially the same once again skew the numbers here a bit, such as with the research track programs, likely account for about 10 of the remaining slots and I'd call these backing up in name only. All told, the situation is essentially the same as it has been for years - if you want to back up, chances are you'll be backing up with FM or IM. There's always a shot at backing-up to some other specialties - even relatively competitive specialties like Gen Sx and OBGYN get a few every year - but it's a riskier option and personal circumstances are likely major factors in walking that tightrope that public data just can't reveal. Overall, backing up remains a viable option for a lot of people who would be comfortable with something like FM or IM as a 2nd or 3rd choice option, so long as they approach their electives planning and CaRMS match strategically.
  20. Na, you're fine. Practice good gun safety and tell your patients to do the same when it's relevant, otherwise it shouldn't have any impact on your career.
  21. Yeah, that's a tough spot. Polite persistence is what I would recommend. Be direct in asking what you're looking for, whether that's a chance to get further into the research project or clinical opportunities. Often these preceptors won't say "no" to any requests, but will try to string you along with vague promises or by saying they'd like to but can't for whatever reason. They want you to keep working for them. Just keep asking. They can't take you along with them in clinic? That's fine, do they have a colleague who would be willing? They'd love to go over your research questions but never sit down to do it? Ask when, provide times. None of those times work? Give a bunch more. Get them to set timelines and firm commitments. When they go past their timelines to get back to you, send them another message reminding them of your earlier discussion. Do it politely, do it respectfully, and don't do it excessively (for example, if they ask for a week to get back to you, give them at least that week), but do it persistently. Don't avoid being a nuisance, just be a reasonable nuisance. My first real research supervisor was an incredibly busy person who was upfront about telling me to annoy them. Best research advice I ever got. It is a bit of a balancing act, as it's possible to go to far, but doing nothing gets you ignored. Keep holding up your half of the deal (do the scut work and do it well) while gently pushing them do hold up their implicit end of it. If in doubt, start slow and ramp up as necessary.
  22. Even if your main role is scut work, that doesn't eliminate other opportunities with this group, but you'll likely have to show additional initiative. Approach the group that you're working for and tell them what your goals are - namely, that you'd like to learn more about the field and that you'd like to learn more about all parts of research, not just the part that you're currently assigned. Depending on their receptiveness, offering to help with analysis and/or manuscript writing could be worthwhile as well. At the early stages, most research opportunities unfortunately involve a lot of scut work. That's a big part of what research is these days. Most preceptors should be willing to trade that scut work for opportunities to learn though, especially for those that show interest. There are those that don't, who just take advantage of students for free labour, and all you can do in that situation is learn that lesson, get out of working for those people ASAP and pick future opportunities more carefully.
  23. If someone applied to both Derm and FM (and wanted Derm first), but didn't get any Derm interviews, they're not likely to rank any Derm programs (even though there's no downside to doing so). Rather, I'd expect most students in this position to start their rankings with FM. In this case, their "first choice" would be considered FM, not Derm, and while I don't think this is an overly common situation, it would skew the stats somewhat to make Derm look less competitive than it actually is.
  24. FM has some specific mental health/therapy billing codes. Don't think they're anywhere near as lucrative as the psych codes though, they just help bridge the gap caused by the fact that mental health visits often take quite a bit of time and so would be a major cost if we could only bill the same as a regular visit (which are much, much faster).
  25. I think that rationale works for residency, but not for medical school. Larger centres have more responsibility for rarer or more unique cases, but these cases aren't high-yield learning cases at the medical student level, where the focus is still rightfully on the bread-and-butter cases. Furthermore, at larger centres, there are far more learners ahead of you in the form of residents and fellows for those unique cases. To the extent a medical student might get more variety of cases in a larger centre, it's by sitting in a corner behind the 4 other people in the room. Meanwhile the student at the smaller centre is learning the important day-to-day cases directly with a staff person, maybe with a single resident ahead of them at worst. To the extent getting into those rarer cases matters, it's during electives, which can be done anywhere regardless of home site. Clerkship is about getting the basics down. No one cares if you can correctly identify a rare genetic disorder that a sub-specialist sees once in their career if you can't read an ECG, or have a good differential for abdominal pain, or treat a COPD exacerbation. The weird stuff is for residency and fellowships.