Interesting Program Directors Take on CARMS

[Snowmen]

17 hours ago, LittleDaisy said:

p.s: what does prescribing biologics mean???

Unless this whole discussion is referring to different biologics, they're a new kind of anti-rheumatic medicine that is ridiculously expensive but also very effective for patients who do not respond to regular DMARDs.

[indefatigable]

10 minutes ago, Snowmen said:

Unless this whole discussion is referring to different biologics, they're a new kind of anti-rheumatic medicine that is ridiculously expensive but also very effective for patients who do not respond to regular DMARDs.

from what I understand, biologics are derived from living cells - and aren't chemically synthesized like regular drugs (not in pill form usu liquid and need to injected).  Could be monoclonal antibodies, etc. - often targeted towards inflammatory cytokines like TNF for RA or Crohn's, receptors for cancer.. 

[la marzocco]

27 minutes ago, marrakech said:

from what I understand, biologics are derived from living cells - and aren't chemically synthesized like regular drugs (not in pill form usu liquid and need to injected).  Could be monoclonal antibodies, etc. - often targeted towards inflammatory cytokines like TNF for RA or Crohn's, receptors for cancer.. 

 

47 minutes ago, Snowmen said:

Unless this whole discussion is referring to different biologics, they're a new kind of anti-rheumatic medicine that is ridiculously expensive but also very effective for patients who do not respond to regular DMARDs.

brand name biologics may be prohibitively expensive , but some generic biosimilars are coming on the market, which should help drive down cost. Though, biosimilars are still not nearly as cheap as conventional chemical drugs. I have heard of a seasoned FM prescribing biologics though they had a solid clinical pharm/toxicology background from grad studies (not sure that changes things?)

[A-Stark]

"Biologics" is fairly broad umbrella term, but I think few if any family doctors would ever initiate one. 

I suppose it does depend on comfort - I'm surprised sometimes when GPs initiate MTX themselves, though the usual thing I see is a patient left on chronic prednisone since the family doc didn't have experience with anything else.

[medigeek]

19 hours ago, ZBL said:

 

Forgive me for being facetious - I know NPs are nowhere near as qualified as FMs, and that was intended as a tongue in cheek comment. I fully recognize that FMs need to be trained to have a broad scope of practice so they can cover whatever comes their way in rural settings, and in these cases I'd say sure they probably need to know the basics of getting things stabilized. However, I think this still has limits such that a FM should not need to utilize the full scope of their allowable practice  - just because someone comes in with a new onset of vasculitis, doesn't mean the FM is or should be the one to set them up on Rituximab, even if they know that's on the treatment pathway. It would be negligent to think this could be managed on their own. By the same token, I don't know of any single example whereby a FM should be starting a biologic. Give the steroids (even this is questionable for things like MS with crazy high doses), get it settled, then consult the specialist. Back in the day FMs would do burr holes, appendectomies, colonoscopies (and some still do according to the US AAFP webpage), but this is historic and there should be no real need for them to do these things today. 

 

However, most FMs are not working rurally, and my original argument was really intended for urban medicine. In an urban setting, even more so, there is no need for FM to be exercising the full scope of their practice given access to specialists - urgent things go to the hospital and it's dealt with quickly. In urban centres, we are still seeing many FMs take on areas of focused practice, which maybe does serve some need for specialized subacute care, but also takes away from needed resources to cover general family practice - which is why I brought up the midlevels comment. Despite this, some FMs do operate perhaps beyond their capabilities, yet still technically within their scope. For instance, I've seen a couple rogue FMs thinking they are plastic surgeons and start ripping off skin leaving horrible scars, asymmetry or missing pieces of face. Technically it is within their scope of practice according to how we have things set up, but just because you can doesn't mean you can do it well or that you should. Same deal for other procedural work or medical management like biologics, heart failure etc, just because you can follow the treatment pathway or saw it once in residency, it doesn't make you an expert. I've seen many cases of things where there is a serious delay in referral to a specialist because the FM has a self-proclaimed interest in the area and their approach failed.

 

All I'm saying is that while these focused practice areas are nice from a career standpoint and are perhaps necessary to serve some community need, and certainly do in rural settings, I think it's incorrect to presume the practice capabilities and outcomes (when exercised to the full extent) are equivalent to what could be done under a specialists care - that is why we have specialists after all, just as it would be incorrect for a cardiologist to start seeing walk-in patients for knee pain in downtown Toronto.  So when those physicians are doing that in an urban setting, with access to specialists readily available, I question why that is the case.

 

Of course this whole discussion came up because @medigeek suggested FMs were giving biologics. I really doubt that’s the case, from a practical perspective, training perspective and insurance perspective (I doubt any insurance company is going to hand out 30K per year drugs without a specialist consult). 

I think you misunderstood what an area of interest is. To have one, you need to be extremely well-read on the topic & have the patient experience in some form. And this is often with specific illnesses, not a whole category. At least point, you become as knowledgeable on X disease as a specialist and develop reasonable experience that's also on par.  

[la marzocco]

6 minutes ago, medigeek said:

I think you misunderstood what an area of interest is. To have one, you need to be extremely well-read on the topic & have the patient experience in some form. And this is often with specific illnesses, not a whole category. At least point, you become as knowledgeable on X disease as a specialist and develop reasonable experience that's also on par.  

That is consistent with what I have seen so far too. I have seen FMs who have an area of interest in HIV and HIV/AIDS management so they have become/are very knowledgeable in this area. Wouldn't call them an ID expert, but at least within the management and prevention of HIV/AIDS, they are definitely on par.

[ZBL]

53 minutes ago, medigeek said:

I think you misunderstood what an area of interest is. To have one, you need to be extremely well-read on the topic & have the patient experience in some form. And this is often with specific illnesses, not a whole category. At least point, you become as knowledgeable on X disease as a specialist and develop reasonable experience that's also on par.  

No, no mistake was made. While I agree that to state you have a focused ability you need to be well read, with appropriate training, and patient exposure, that is definitely not always the case. Skin surgical skills is a good example as I mentioned previously. Here’s a series of papers in CMAJ that highlights exactly the points I was trying to raise. 

1. http://www.cmaj.ca/content/cmaj/183/18/E1287.full.pdf

2. http://www.cmaj.ca/content/cmaj/183/18/E1289.full.pdf

3. http://www.cmaj.ca/content/cmaj/183/18/E1291.full.pdf

 

I’m not necessarily saying one way or the other, just that these are issues that bear thinking about on the large scale. 

[ZBL]

1 hour ago, A-Stark said:

"Biologics" is fairly broad umbrella term, but I think few if any family doctors would ever initiate one. 

I suppose it does depend on comfort - I'm surprised sometimes when GPs initiate MTX themselves, though the usual thing I see is a patient left on chronic prednisone since the family doc didn't have experience with anything else.

Agree. But thinking more about it, I seriously doubt insurance companies would sign off on a 30K per year drug without having a specialist consult. Maybe @medigeek saw a FM giving MTX or some other DMARD?

[NLengr]

On 4/30/2018 at 1:02 AM, bearded frog said:

 

I'm a resident. Guess how many pathology slides I have interpreted and will be expected to interpret prior to finishing.

I had to interpret pathology slides during my royal college exam. I'm a surgeon. 

[Katee87]

Nursing wants expand their scope to include methadone 

https://www.google.ca/amp/s/www.cbc.ca/amp/1.4646256

I thought this was an interesting conversation starter. We do have a shortage of physicians that have the training. I can kinda understand NP as they are advanced practice. 

 

 

[DermJuly2018PGY1]

10 hours ago, Katee87 said:

Nursing wants expand their scope to include methadone 

https://www.google.ca/amp/s/www.cbc.ca/amp/1.4646256

I thought this was an interesting conversation starter. We do have a shortage of physicians that have the training. I can kinda understand NP as they are advanced practice. 

 

 

Say no to midlevels. NO NO and NO. They will take over medical practice.

[Organomegaly]

On 4/29/2018 at 11:17 PM, medigeek said:

 

On 4/30/2018 at 9:44 AM, JohnGrisham said:

I wouldn't be opposed if they made step 2 CK (clinical knowledge) the "standardized Canadian test" for comparison. It is far better a test than step 1, and highly clinically relevant.

I have written all of my Step exams bar the Step 3. 

I actually strongly agree with this. The Step 1 is a frustrating exam. That exam WILL test minutiae, histology, biochemical enzymes, obscure pathology knowledge, etc that will never be called upon clinically. The Step 1 almost tests your ability to assimilate a large fund of knowledge and work hard. Though as rmorelan has mentioned, success on it correlates with success in residency and fewer patient complaints. 

The Step 2 CK, in contrast, is a very good exam. It will test your ability to apply clinically relevant knowledge. There ARE obscure factoids here, but they are factoids that could become clinically relevant. As part of the testing you'll have to interpret data, have a strong fund of knowledge and know your pathophysiology/therapeutics well. It's a tough exam, but it's also quite fair. There are no vague clinical vignettes a la LMCC Part I. Adopting this as part of the Canadian residency selection process (as ONE of many other factors) would add some objectivity to the process. 

[Organomegaly]

On 5/1/2018 at 1:20 PM, Edict said:

Yeah... Mac claims that but... yeah its not true... at least for test scores. 

Mac generally performs about middle of the pack on the LMCC Part I and slightly above average on the LMCC Part II actually

[medigeek]

10 minutes ago, Organomegaly said:

Mac generally performs about middle of the pack on the LMCC Part I and slightly above average on the LMCC Part II actually

Who performs the highest/lowest?

[Edict]

3 hours ago, Organomegaly said:

Mac generally performs about middle of the pack on the LMCC Part I and slightly above average on the LMCC Part II actually

We do perform above average on the Part II, but we perform below average, not bottom but below average on the Part I. Mac will say it is middle of the pack, but it is closer to the lower end of middle of the pack.  

[Edict]

2 hours ago, medigeek said:

Who performs the highest/lowest?

I don't think we know, this information is a closely guarded secret. Institutions get only their own performance and the average. A lot of institutions don't even share their results with each other. Certainly, the lowest performing school is not going to want to publish that information. 

[rmorelan]

16 hours ago, Edict said:

I don't think we know, this information is a closely guarded secret. Institutions get only their own performance and the average. A lot of institutions don't even share their results with each other. Certainly, the lowest performing school is not going to want to publish that information. 

no but some of the higher ones aren't so afraid so sometimes it pops up in Dean's reports. If you pull enough of them together and do a process of elimination you can get some clues. Plus sometimes you will notice a school suddenly stop reporting which is suspicious for them having a bad year. 

I will say this though - the scores don't appear to be all that far apart regardless of where you go overall. I think that is just reinforcing that it is  hard to get into medical school and thus most students are bright/hard working, and the schools all get roughly the same amount of money per person so there isn't huge educational resource differences. 

 

[goleafsgochris]

27 minutes ago, rmorelan said:

no but some of the higher ones aren't so afraid so sometimes it pops up in Dean's reports. If you pull enough of them together and do a process of elimination you can get some clues. Plus sometimes you will notice a school suddenly stop reporting which is suspicious for them having a bad year. 

I will say this though - the scores don't appear to be all that far apart regardless of where you go overall. I think that is just reinforcing that it is  hard to get into medical school and thus most students are bright/hard working, and the schools all get roughly the same amount of money per person so there isn't huge educational resource differences. 

 

I went to Mac and thought we might perform worse.  Its just one year, but everyone I know passed.  I think the stuff Mac is shaky on (anatomy, pharmacology) doesn't come up that much.

[Organomegaly]

On 5/5/2018 at 6:53 PM, Edict said:

We do perform above average on the Part II, but we perform below average, not bottom but below average on the Part I. Mac will say it is middle of the pack, but it is closer to the lower end of middle of the pack.  

Which is fine imo

[Edict]

4 hours ago, Organomegaly said:

Which is fine imo

No question it is fine, but I think a school should strive to be the best no?

[Lactic Folly]

Different values. McMaster's Faculty of Health Sciences vision is:

Within a culture of innovation, exploration and collaboration, we lead by learning from what was, challenging what is and embracing what could be."

The vision for University of Alberta Faculty of Medicine & Dentistry (a school which has promoted their students' LMCC results in the past) is: 

To build an exceptional socially accountable Faculty through leadership in education, research and patient care and to be recognized as graduating highly skilled doctors, researchers, and health care professionals for Canada. (italics mine)

[Edict]

On 5/9/2018 at 9:38 PM, Lactic Folly said:

Different values. McMaster's Faculty of Health Sciences vision is:

Within a culture of innovation, exploration and collaboration, we lead by learning from what was, challenging what is and embracing what could be."

The vision for University of Alberta Faculty of Medicine & Dentistry (a school which has promoted their students' LMCC results in the past) is: 

To build an exceptional socially accountable Faculty through leadership in education, research and patient care and to be recognized as graduating highly skilled doctors, researchers, and health care professionals for Canada. (italics mine)

Very true, the culture of each school is different. 

[mavrik13]

Just wanted to add a point - what makes part of the process so difficult (from someone who has interviewed on a CaRMS panel, evaluating applicants and reviewing application packages) is that each school sends different information. Personally I recall comparing candidates from the same school with each other when schools would send a useful MSPR which 'grades' students, acknowledging there are issues with interpreting a single result, but if one candidate has 80% excellent rotation grades and another is 80% average rotation grades, it is a useful data point.

I personally don't think grading of MS1/2 exams is particularly relevant - does my knowledge of the Krebs cycle correlate with my current skills as a resident? I would say not...

[A-Stark]

About the only school that provides really meaningful MSPRs is UBC. Everything else is about parsing generic comments. 

[FlameGrilledChicken]

3 hours ago, A-Stark said:

About the only school that provides really meaningful MSPRs is UBC. Everything else is about parsing generic comments. 

Could you expand a bit on how UBC's is more meaningful? Are there any pieces of info they provide that separate them from the rest?