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Five strategies to improve medical training -- to reduce stress and boost expertise


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Agreed on increasing residency positions, who doesn't.

Not sure what he means by "learn local". There's no concrete plan suggested for that one. Does he mean that residency programs would prioritize their own medical school students?

I would only be in favour of delaying specialty choice if it does not prolong residency.

And I would only be in favour of reinstating the rotating internship if they brought back the GP license with it.

Not sure about what he means by reducing exam studying time either. Does he mean fewer exams in medical training? If so, then sure.

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from the article med student debit jumped 90K from 70 to 160K in three years (2014-2017)? 

ahhhhh no it didn't.

I like the goal about the article although I find some of the points confusing

1) Sure we can increase spots - probably not a bad idea. But you cannot talk about that without also talking about how the government can control how we have the right number of doctor in each field. We have tried every other way of limiting things - advertising, incentivizing directly, increasing pay.... I don't like restricting things for many of the reasons mentioned but I haven't come up with any other way to say insure we have the a reasonable number of each type of doctor either. People will always try to get into particular fields if there is a spot - regardless of whether we need people in that spot (not fair 5 years down the line either with tons of unemployed doctors - how do we avoid that?)

2) One of the advantages of our system is that we don't really have local approach to many things. As a med student I didn't want some form of local bias in my 4th year - I wanted to expand my search to the entire country as I was applying across the country. That was how I learned all the various programs etc. Not say the entire process wasn't stressful and overly complex. 

3) We don't have internship - and we are moving farther away from it even with competency based education. Re adding it would be a huge change (just after we made a huge change with again competency based training). Unless internship is also at the same centre you did medical school or future residency it (like the US) would involve a second move - which is an entire other level of pain ha - and hugely stressful I might add. As much as I really do think we should be generalists that expand to other fields that is a really hard thing to do at this point. without making training longer  

4) goes into 3) - adding internship is hard to do and delays learning about what you are actually going to end up doing. I respect the need to understand other fields and do find that knowledge useful quite often I can tell you most residents find their off service rotations as likely annoying time wasters quite often until you get to do what you are "supposed" to be doing (more warm bodies for the call pool). Also as medicine moves further and further along it is harder and harder to do anything useful in another field with only short exposure. They aren't structured so that you can "gain an understanding" of another field. They are designed so that various fields that need some form of coverage in fact have people for it. I am not sure they were ever designed for that purpose truly in mind. 

5) Ok you want to reduce the time required to prepare for the exam? Zero mention of how that would happen without also reducing the amount of knowledge you know (granted not all of that knowledge is ha the most useful). Sure there is some of that but as much as I really really hated parts of 5th year that intense study time made me a much better doctor. There is no substitute in medicine for knowing things, and knowing things only comes either from studying very hard or clinically working. I now see rare things relatively often in practise - things that never saw in residency and only know about because I studied - basically clinical experience alone is not enough to know the "zebras". Without that I would not be as effective - and you have to be effective in the end above all else. All of medicine is getting MORE complex with more things to know - in the face of that I am not sure how you are supposed to study less. 

There are ways to reduce some of the stress and make the system better - ha, but it would be nice we can pro/con these things before they just get thrown out there. The system set up as it is has its reasons for existing. We can change it but the plan has to address both sides.

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2 hours ago, la marzocco said:

https://nationalpost.com/pmn/news-pmn/five-strategies-to-improve-medical-training-to-reduce-stress-and-boost-expertise

1. Increase residency positions

2. Develop a ‘learn local’ strategy

3. Delay specialty selection

4. Reinstate the rotating internship

5. Reduce preparation time for exams

Thoughts?

I agree with rmorelan. I read over the internist's post on how to reduce the medical students' and residents' stress.

1. I definitely agree with increasing more residency spots for CMGs, one solution is to cut down IMG residency spots and allocate it to CMGs. The CMGs who went unmatched, essentially have an empty MD title with no future job promise. It's possible to match into the subsequent years, but the tragic case of Dr Robert Chu showed us that the CaRMS process is very competitive, and the system is flawed and leaves the unmatched CMGs into a loophole.

2. Develop a learn local strategy: I disagree, I think that you definitely learn more about your specialty of interest, and about your potential future residency programs by doing electives across the country. If you always stay in the same medical school, same place for residency, and same school for fellowship, you will end up interacting with the same pool of staff physicians, and being too comfortable in your "bubble". Medicine is always changing, and it is to our advantage to explore our options.

By adapting a "learn local strategy", does that mean that each residency program favour its own medical students? I think that the program should select the best candidates regardless of their school of origin.

3. Delay specialty selection & reinstate the rotating internship: CFPC has made it very clear that if you want to become a family physician in Canada, you have to go through the 2 year of family medicine residency. There has been more speculation about CFPC wants to extend Family Medicine into a 3 year residency for the upcoming cohorts, as they find our 2 year of training to be too short for us to be competent family physician. 

I don't think that it's realistic at this point to advocate for rotating internship, and it would be a pain for a future internist to do 1 year of off-service rotation of peds, psych, obs-gyn. Or for a pediatrics resident do do the 1st year of residency off-service in adult medicine. I doubt that you can become a generalist after 1 year of rotating internship, as medicine has become more and more complex. 

5. Reduce preparation for exams: the author seems to say that give less time for medical students & residents to study for licensing exams, which is not realistic. At the end of day, you need to pass LMCC, CFPC, Royal College Exam to be able to practice independently. You should not take the exams lightly, if anything, the residency program should advocate for more time off for residents, and more protected study time. 

The patient clinical opportunities will come once you become a staff, and when you realize that you are the most responsible physician :) 

 

 

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Reduce study time for the royal college exam? WTF? We could make it even easier and just fail everyone right off the bat instead of making them write it in that case.

The exam is insane, and yes, the pass rate is high but that's because everyone goes insane for a 12-24 month period eating, breathing and sleeping studying. If you didn't, you wouldn't pass. 

I also agree that without that intense exam study period, we would be turning out poorer quality physicians. You don't get enough knowledge solely with clinical experience with anything but the most bread and butter cases to be competent with them. The depth of knowledge is one of the main things that's separates us from most midlevel providers.

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Agree with the critiques above:

1) no brainer - esp when we are in situation with some students almost being guaranteed to be unmatched.  Nonetheless the general public won't have a lot of sympathy for med students feeling they lack choice, when doctors of any kind are often thought to be wealthy and privileged.  I think as medical professionals, we have to accept that ultimately we don't necessarily always get our first choice and have to adapt to that from day one. 

2) I can see policy makers picking up on this one, although I think it defeats the entire purpose of CaRMs if away electives are disallowed or strongly discouraged.  There's some implicit home-school management/control suggested - "The proposed changes would also right-size our medical work-force."  

 I agree with the previous statements regarding the professional advantages of exposure and visiting different locations during electives.  I concur that away pre-CaRMs electives have been a highlight of my medical education, allowing me to extend my options and competence, despite being restricted to a maximum of 4 (although 12 weeks) and occurring at the beginning of clerkship (for my curriculum).

3-4) Similar points but not realistic in today's world.  The 8-week elective cap in theory could add some diversification, which isn't addressed in the article - in fact one of the examples given couldn't occur with the cap.

These issues are more likely to occur without a good clerkship structure - i.e. too many early electives or some have suggested with accelerated 3-yr MD programs.

5) I think the exam situation isn't that huge a stressor in Canada with the exception of the 5-year RCPSC (and 3 yr IM exam).  There's some question of the pertinence of the LMCC Part II, for some specialists, so maybe this could be addressed.  Ultimately I think the different specialties are best placed to determine the level of exam knowledge needed - and programs should advocate for more study time as suggested above.  However,  I think this more of a resident rather than med student question.   

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4 hours ago, la marzocco said:

https://nationalpost.com/pmn/news-pmn/five-strategies-to-improve-medical-training-to-reduce-stress-and-boost-expertise

1. Increase residency positions

2. Develop a ‘learn local’ strategy

3. Delay specialty selection

4. Reinstate the rotating internship

5. Reduce preparation time for exams

Thoughts?

1. Unlikely

2. wut?

3. Unnecessary

4. Not happening

5. lol

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56 minutes ago, GrouchoMarx said:

Rotating internship with general license is the best answer and this is undeniable

you want basically family doctors running around with a single year of training? Either that or a general license would mean nothing. I like the concept but I don't know how that would work now without killing people left and right. 

I don't think that was truly all that safe with one year in the past - I have absolutely no idea how you can become close to being family doctor with only year currently. I don't know how you do it in 2 years to be honest (which is why may other places take longer). Wouldn't surprise me if they are thinking of making it longer in Canada as someone pointed out. 

Plus a rotating internship isn't even family medicine any more - it would classically have a whole bunch of stuff that would be nearly useless for that (like rotating through months of modern surgery). 

I think the basic problem is that medicine is just too complex anymore for this sort of generalization without restructuring the entire system (which for a general license would be to reconfigure all of medical school towards truly that end - where right now it definitely is not). As much as i would love to have a general license as a structured platform to launch from I don't think I could come close to holding all of what I have to know for both that and my primary field in my head at the same time. 

Of course I am ignoring the family doctor politics here ha -which in the real world would be hard to ignore - they relatively easily at this point block anything even close to a general license. 

 

Edited by rmorelan
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also he makes the point that it is hard to make a choice after only two years of superficial training in various areas. That actually isn't a bad point - it is hard to know a lot of fields well, although you could argue it is closer to 2 years and 8 months as you don't start to pick electives until around 2/3 of your 3rd is done (for the 4 year programs), and ideally - but not always - you can stick stuff you know you aren't interested in at the end. Clerkship is more than superficial work in the field. Actually most rotating internships are pretty superficial as well (good luck getting exposure to the 10 random fields he listed in the article). 

If you were to this - and I am not saying it is a great idea - then it might make sense to have the internship build into medical school. Up med school to 5 years, have the 4th year rotating internship, 5th year electives etc and the part 1 exam, and cut residency programs by one year to make the time the same. I have ignored the fact that there is a year of pay in there that I just made disappear ha but you know "magic". That would give everyone more time to figure things out I suppose

 issues would be that

a) figure out that pay thing - people deserve to get paid ha.

b) "interns" right now are doctor, and med students aren't - that introduces issues with what you are allowed to do.  

c) most programs do have off service electives right now but they aren't necessarily a year of them (rads had some of the MOST and it only had 10 months where I was at).

d) A lot of programs use longitudinal learning in family medicine and other similar programs - something a cardiologist like the author may not have noticed - you follow the same patients for 2 years part of the time to learn that aspect (its an important one). Rotating internship chops all that up into little pieces - and longitudinal learning is way better than intense shorter training that is never done again (like most of my off service stuff)

I work in the US right now - and rotating internship are still the norm. Haven't run into anyone that thinks they are a good idea anymore, but are just something you have to push your way through to get to the real stuff. Cannot say I blame them for that attitude.

 

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4 hours ago, rmorelan said:

also he makes the point that it is hard to make a choice after only two years of superficial training in various areas. That actually isn't a bad point - it is hard to know a lot of fields well, although you could argue it is closer to 2 years and 8 months as you don't start to pick electives until around 2/3 of your 3rd is done (for the 4 year programs), and ideally - but not always - you can stick stuff you know you aren't interested in at the end. Clerkship is more than superficial work in the field. Actually most rotating internships are pretty superficial as well (good luck getting exposure to the 10 random fields he listed in the article). 

If you were to this - and I am not saying it is a great idea - then it might make sense to have the internship build into medical school. Up med school to 5 years, have the 4th year rotating internship, 5th year electives etc and the part 1 exam, and cut residency programs by one year to make the time the same. I have ignored the fact that there is a year of pay in there that I just made disappear ha but you know "magic". That would give everyone more time to figure things out I suppose 

Some four year schools have different clerkship structures - my school has had for example all electives at the beginning of clerkship (changed from now on). Queens is another school that has electives early (after 6 weeks of clerkship) which means making choices before a lot of core rotations - this was discussed on another thread.   Three years schools obviously have the same type of constraints.

 So I wonder if his concerns are exacerbated it by being at queens - instead of facing a typical four year clerkship structure.  Because as you mention normally people make decisions regarding electives little later in fact the AFMC elective deadline has been recently pushed forward - I.e decision can be made a little later.

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1 hour ago, tere said:

Some four year schools have different clerkship structures - my school has had for example all electives at the beginning of clerkship (changed from now on). Queens is another school that has electives early (after 6 weeks of clerkship) which means making choices before a lot of core rotations - this was discussed on another thread.   Three years schools obviously have the same type of constraints.

 So I wonder if his concerns are exacerbated it by being at queens - instead of facing a typical four year clerkship structure.  Because as you mention normally people make decisions regarding electives little later in fact the AFMC elective deadline has been recently pushed forward - I.e decision can be made a little later.

that is true - and if you happen to have that structure you are going to have issues. One of the advantages of Western and to a point the other schools that adopted that structure was electives after the core clerkship program - so everyone doing electives would have covered the same material (i.e. all of it). Thus you have an advantage during electives if you are trying to impress people. That is great until you have everyone doing that and we have people only trying to fit everything into the exact same 4 months - which is impossible and thus no one can get reliably electives ha. Even if you aren't that extreme you shouldn't start with electives. 

while that late structure may not work overall with everyone the doing them all up front just sounds....well stupid. Why would you give your students the disadvantage of a) not even testing other areas to see what they like prior to electives, b) force them to chose I guess extremely early (which I think he mentioned - sounds like he is using Queen's as a particular example). c) electives are NOT JUST about you learning things - they are about you getting letters of reference, and honing skills to impress. How are you supposed to do that on a surgery elective for instance if you haven't even scrubbed in for real yet (and yes I have run into surgery keeners stuck on elective at a really dumb early time - and had to show them how to actually scrub and gown in when I was a clerk - I felt so bad for them - in 6 mos they probably made a solid clerk but really at that point it was painful to watch. Zero situational awareness in the OR.) Guess who didn't get a LOR on that elective...and that reduces the chances of matching downstream. 

 

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I agree with you and see your point wrt to having only late electives!  I suppose there has to be some balance - either extreme is problematic.  Nonetheless, I tend to to think that later electives should be more of a default rather than early electives.

I was able to overcome the disadvantage in c), to some extent, but almost certainly later electives would have helped even more.  In my own case, I took initiative for observation/shadowing to help with a) and b), although this wasn't part of my curriculum at that point.  My school even had restrictions on 2 week electives - but for new curriculum they seems to have some later electives and permit more 2 week electives.  

@Edict has expressed similar frustrations to a)-c) in the past.  

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Yes, late electives are much more useful. The best combination is a few early electives to explore and mostly late electives to impress. 

re: a mandatory rotating internship, i'm not sure i'm for that. Unless it can be configured to be relevant to your chosen specialty, I could see it being a waste for some specialties like surgery for example. 

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On 4/22/2019 at 11:27 PM, Butterfly_ said:

I think being a good, generalist family physician is very difficult. I don't think we should underestimate what family doctors do.

To be fair, there's a lot of bad family physicians out there. And I think what separate good family physicians from awful ones likely isn't an extra year of residency but rather the discipline and motivation to keep learning and reviewing throughout their career.

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2 hours ago, hero147 said:

To be fair, there's a lot of bad family physicians out there. And I think what separate good family physicians from awful ones likely isn't an extra year of residency but rather the discipline and motivation to keep learning and reviewing throughout their career.

And the motivation will come naturally if the physician themselves have passion for family medicine and not just see family as a backup or “easy”. 

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1 hour ago, Butterfly_ said:

And the motivation will come naturally if the physician themselves have passion for family medicine and not just see family as a backup or “easy”. 

Well those 2 aren't mutually exclusive. I also fail to see how adding an additional year has improved that perception.

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8 hours ago, Butterfly_ said:

I don’t think one year is sufficient for anyone to feel ready to become a practicing physician of any kind.

I'm not sure if dentistry school prepares you to be perfectly comfortable as a dentist or if articling prepares you to be perfectly comfortable as a lawyer. Your proficiency grows as you continue to work in the field. In those other fields, you learn from your seniors but you're still independent and are free to compete in the job market. If people are truly incompetent then they just won't find work. Right now we are denying students from even competing in the job market if they cannot switch into an FM program. 

 

4 hours ago, GrouchoMarx said:

why not an apprenticeship model like dentistry does?

As a junior staff, I learn plenty from my more senior colleagues and this process works even outside of the confines of a rigid residency program. I will say that I agree that you may not be a fully capable doctor in FM with just 1 year of training, however, I find it extremely hard to believe that you cannot do anything with just an internship year. There seem to be a decent amount of specialists who would love to fall back on something like a walk-in for geographic flexibility. The stories I read in the news about senior residents unable to switch residency programs into FM and thus unable to acquire an independent licence is also saddening. I work with many R1s and early R2s and I can say they are more capable than we give credit for. They may not be able to handle everything but they can handle simple clinics or office type jobs. I would be happy to hire them as clinical associates over an NP or a PA. 

With regards to the general article:

1) I agree we just need enough residency spots to ensure that students have flexibility. However, I would say this would be hard to implement due to limited government dollars and their desire to make more FM doctors to satisfy societal needs. 

2) I think we shouldn't be restricting people based on their school if that's the implication. We should allow students to explore different medical schools and different patient populations. I agree with the article when they mention that the electives and CaRMS interview process can be very expensive and I think we should not have to impose this "education tax" on students if they need to travel to be competitive. 

3) I agree with this. I think students have to figure out too early what they want to do. This can be disastrous for the match if they figure things out too late. Now I'm sure people will point out how they were able to match with no electives or whatever, but if we want to look at the average situation I think generally the more focused you are with electives the better your chances will be. My Vet friends tell me that when they finish they are able to function as GPs and if they want to specialize in Ortho or something they can go into later. I hear similar things from my Dentistry friends. 

4) I agree with this. I honestly think there should be a "default" type of doctor that we all qualify as and then we build specialty training on top of it. Perhaps some of the training will be redundant but I would say that a lot of the FRCPC programs are 5 years in length compared to their US counterparts which are shorter so I'm sure there is some time we can carve away.

5) The exams as they stand are difficult enough that we barely have enough time. I would say that we should probably make these exams less about esoteria and memorization of useless minutiae and instead be focused on testing if you will be a good practical physician in your specialty. However, you also need to learn about topics that are too rare for you to see during your residency just in case. It's a hard balance to maintain and I'm not sure what the answer is here. 

Overall I think we need to take actions that increase optionality to our students. Things like delaying the specialty choice and making sure that students are actually trained and can fall back as a "general doctor" would prevent some of these tragedies we hear about while also align us closer with other professions such as veterinary medicine or dentistry.  

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48 minutes ago, blah1234 said:

I'm not sure if dentistry school prepares you to be perfectly comfortable as a dentist or if articling prepares you to be perfectly comfortable as a lawyer. Your proficiency grows as you continue to work in the field. In those other fields, you learn from your seniors but you're still independent and are free to compete in the job market. If people are truly incompetent then they just won't find work.

I  agree that R1's are very knowledgeable and that a physician's proficiency will grow after residency, but there still needs to be sufficient time to ensure that the basic training has been received. 
Once again, I think the difficulty of generalist medicine is being underestimated. We already have the shortest family medicine residency in the world--we shouldn't make it any shorter.

Also, family medicine is not just about practicing medicine. Most family physicians are business owners as well. No one in medical school teaches you how to run a medical office. Learning to become a business owner and a practicing physician in one year seems like an unrealistic timeline. 

Perhaps starting a practice may not be as big of a problem in Ontario where family health teams are prevalent, but in other provinces like BC, fee for service is the main model. 

If students want to become FM docs then the ministry should fund more FM spots and allow for transfers into FM spots.

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22 hours ago, Edict said:

Yes, late electives are much more useful. The best combination is a few early electives to explore and mostly late electives to impress. 

re: a mandatory rotating internship, i'm not sure i'm for that. Unless it can be configured to be relevant to your chosen specialty, I could see it being a waste for some specialties like surgery for example. 

Agree it’s too hard to make a one size fits all rotating internship. That said, some specialties like radiology, dermatology and maybe some others still maintain a rotating internship model for their first year or two of residency that comprises pediatrics, IM, emerg, and surgery intermixed with a few rotations in their own discipline. Pretty broad training. 

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23 minutes ago, ZBL said:

Agree it’s too hard to make a one size fits all rotating internship. 

What if it was split into rotating internships geared towards students leaning more towards medicine or surgery? There would need to be flexibility to transfer and get credit to the other.

9 hours ago, Butterfly_ said:

I don’t think one year is sufficient for anyone to feel ready to become a practicing physician of any kind.

One year rotating internship + one year dedicated to FM makes sense. I think my FM program only has 11 months of FM total with the rest being off service. A rotating internship would actually give me more time training in FM :huh:

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31 minutes ago, Butterfly_ said:

 

Also, family medicine is not just about practicing medicine. Most family physicians are business owners as well. No one in medical school teaches you how to run a medical office. 

I have never heard of anyone learning that in residency either, no matter what the specialty. At best, you get some very superficial education. I know I didn't get much at all. I learned it all myself, from my colleagues or from my parents (my family had a small business before my parents retired).

Most physicians in general are business owners. The majority are still FFS or AFP.

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