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

[blah1234]

2 hours ago, Butterfly_ said:

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.

 

1 hour ago, NLengr said:

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.

I would agree and say that in my previous profession and according to my friends in other regulated professions we did not receive education regarding how to run a business. I would have to disagree with you on how residency needs to be long enough to accommodate teaching business skills.  It doesn't really exist in many programs and it doesn't really exist in other professional training.  

I would say that you get a lot of the basic training in R1. I'm not saying that we let these internship people go wild with running full family medicine clinics as they are not going to be family doctors. Rather these people are capable enough to work under an FM or specialist in seeing patients in a walk-in or some sort of basic clinic (hypertension). Every fresh R2 I met knew when to ask for help and knew their limits. If we are trusting NPs and PAs with some degree of autonomy in clinics then we should have no trouble with people who have just completed an internship year.  

An internship year alone in the countries that still offer them doesn't offer everyone the flexibility of being a full FM but gives them limited practice options. I think the push to make FM its own specialty hasn't really resulted in more respect and has resulted in a more convoluted system with two colleges.

I don't think every medical student wants to be a family doctor, but I do think that every medical student wants to be a doctor and right now I don't think the system is accommodating that. Not everyone is destined to love their jobs in medicine but we don't allow for a "default" type of doctor and FM programs want people who actually are passionate about FM. What happens to the students who need FM because

1) They want to finish ASAP and FM is the shortest path?

2) They can't handle the rigour of call or demands in other specialties?

3) They weren't competitive for the specialty of their true interest?

4) They don't like medicine in general but they have student debt or bills to pay?

That's the main issue I have with the notion that we should just make more FM spots. These FM programs want passionate students ideally, but we have a large category of students that need something to help move on with their lives and sometimes those students are falling through the cracks because FM doesn't want to be seen as a "backup" or "second class". An internship would be a better solution I think, but we may be too far down the road to reimplement it. 

 

 

[NLengr]

3 hours ago, blah1234 said:

 

That's the main issue I have with the notion that we should just make more FM spots. These FM programs want passionate students ideally, but we have a large category of students that need something to help move on with their lives and sometimes those students are falling through the cracks because FM doesn't want to be seen as a "backup" or "second class". An internship would be a better solution I think, but we may be too far down the road to reimplement it. 

 

 

More family med spots wouldnt be so bad if there was a decent way to re-enter the match or change specialties later on. Right now carms is a one shot deal essentially. You are almost stuck with whatever you match to for the rest of your life. 

[blah1234]

34 minutes ago, NLengr said:

More family med spots wouldnt be so bad if there was a decent way to re-enter the match or change specialties later on. Right now carms is a one shot deal essentially. You are almost stuck with whatever you match to for the rest of your life. 

I agree the system right now is too rigid. We don't give students enough flexibility or optionality and make medicine a straight line. You should be able to specialize whenever you feel like you have a strong application and you have enough interest. My Australian colleagues tell me that over there you apply to specialist programs after general training and you can apply as many times as needed (although there is the downside of starting a surgical program after years working as a general resident). I feel like that system seems more in line with what I am advocating for. 

[JohnGrisham]

4 hours ago, blah1234 said:

I agree the system right now is too rigid. We don't give students enough flexibility or optionality and make medicine a straight line. You should be able to specialize whenever you feel like you have a strong application and you have enough interest. My Australian colleagues tell me that over there you apply to specialist programs after general training and you can apply as many times as needed (although there is the downside of starting a surgical program after years working as a general resident). I feel like that system seems more in line with what I am advocating for. 

UK is somewhat similar. But at the same time why would I want to be a resident for much longer? In the UK you have to do two basic generalist years..then 3 more years at a minimum to be a GP and then 5-8 more years for specialties. And its competency based so on average most people take longer too.

Barring the fact that med school is 6 years instead of undergrad+med of 7-8yrs minimum but often longer here...the post grad residency training time is much longer.   Some people wouldnt mind that, as hours are more reasonable etc. Others would rather get it over with too. Hard to say

[blah1234]

11 hours ago, JohnGrisham said:

UK is somewhat similar. But at the same time why would I want to be a resident for much longer? In the UK you have to do two basic generalist years..then 3 more years at a minimum to be a GP and then 5-8 more years for specialties. And its competency based so on average most people take longer too.

Barring the fact that med school is 6 years instead of undergrad+med of 7-8yrs minimum but often longer here...the post grad residency training time is much longer.   Some people wouldnt mind that, as hours are more reasonable etc. Others would rather get it over with too. Hard to say

It is a difficult balance. I think more reasonable hours could help alleviate some of the burnout people might be feeling. Although there is frustration on the lack of control as a learner on our schedules I do find that the difference between working 60 vs 80 vs 100 hours a week is dramatic the higher you go. Even if the training was longer would it be more tolerable with saner hours?

I think another way to mitigate the training length is to make medicine entry possible from high school like Quebec or the UK. 

Maybe many people would just want to push through and I personally am glad it is all done now that I'm on the other side. However, when I think about my policy leanings I reflect on if this system is worth the ~100 students/year that fall through the cracks. Having heard of a mentee pass away from all this makes me favour a system that lets students become what they have been training for. I don't think students should be graduating with a piece of useless paper and a mountain of debt.  

I think there are also variables at play like tuition costs. If we were able to reduce tuition to much more affordable levels then I think we could also reduce the burden of not matching as well. However, I don't think we will ever reach the US in terms of offering a breadth of non-clinical careers so I think students will still be primarily limited to doing a residency program. 

[insomnias]

The whole length of training vs hours of training is often presented as a dichotomy; however, I would argue that they're not as intertwined as people like to make it out. How is it that Switzerland caps their residents at ~40-50h/week, maintains the same length of postgrad training we do, and then has the RCPSC recognize their residencies as equivalent to ours?

[NeuroD]

2 hours ago, insomnias said:

The whole length of training vs hours of training is often presented as a dichotomy; however, I would argue that they're not as intertwined as people like to make it out. How is it that Switzerland caps their residents at ~40-50h/week, maintains the same length of postgrad training we do, and then has the RCPSC recognize their residencies as equivalent to ours?

Agreed. We are the only country among our peers without government rules capping the maximum number of hours/week.

[blah1234]

19 minutes ago, PhD2MD said:

Agreed. We are the only country among our peers without government rules capping the maximum number of hours/week.

Caps don't mean anything if the culture doesn't support it. I have heard from surgeons that despite hour caps in the US many residents are still pressured to report normal weekly hours despite working non-stop.

I am curious about how the Swiss system works. I have no doubt you can learn plenty working 40-50 hours a week but how do you build comfort and stamina working long hours? While staff life is easier than residency many of my colleagues still put in long hours in the community in order to cover services. Not everyone gets to work the 40-50 hours even after they finish residency and some still have to work well into the night on a regular basis. 

[GrouchoMarx]

19 hours ago, blah1234 said:

Caps don't mean anything if the culture doesn't support it. I have heard from surgeons that despite hour caps in the US many residents are still pressured to report normal weekly hours despite working non-stop.

I am curious about how the Swiss system works. I have no doubt you can learn plenty working 40-50 hours a week but how do you build comfort and stamina working long hours? While staff life is easier than residency many of my colleagues still put in long hours in the community in order to cover services. Not everyone gets to work the 40-50 hours even after they finish residency and some still have to work well into the night on a regular basis. 

The stamina argument is poor. Its easy to find the stamina to do medicine at any hour for as long as possible if you are the one responsible for the patient's outcome and you are paid appropriately for your services.

Residency is as brutal as it is because of $$$. Residents are cheaper than attendings or even NPs and can't leave if the workplace is toxic.

This is why i hate the match. It is anticompetitive. Once a resident is in a program they are the program's plaything without recourse. The program makes money off residents as half of the GME allowance goes directly to the program, and the government saves money by not having to pay attendings or NPs to cover call or wards.

In the old days docs had a bit more power over this as they could just quit, or change programs, if the one they were at was not working out.

This is why the rotating internship model was good. It was flexible. There is no argument against it now that nurses and pharmacists are practicing primary care independently.

[indefatigable]

On 4/26/2019 at 11:25 PM, blah1234 said:

I think another way to mitigate the training length is to make medicine entry possible from high school like Quebec or the UK. 

Slight clarification - entry in QC is possible from CEGEP, where students finish with equivalent to first year university and which is similar to a junior college, but not high school.  

Nonetheless the point is the same - training length is cut-down significantly on average.  

Side points/Off-topic: It's interesting that in QC where the med interview is uniquely based on academic results, that students will be almost always admitted based on 1.5 - 2.5 yrs of post-secondary results vs usually 3+ yrs of experience in ROC.  Clearly saves students $$ and time if unsuccessful, since CEGEP costs much less than university and is available throughout the province.  Also same payoff for smaller time/$$ investment.  

Moving away from pre-reqs in ROC also decreases opportunity costs for unsuccessful applicants.  While university educational attainment is lower in QC than ROC, some argue the mix of practical and theoretical training available at CEGEPs minimizes degree inflation often seen in ROC (college after university).  Although I doubt degree "deflation" could realistically occur in the ROC given the stigma against colleges, it nonetheless has some advantages.   

[Hanmari]

1 hour ago, GrouchoMarx said:

The stamina argument is poor. Its easy to find the stamina to do medicine at any hour for as long as possible if you are the one responsible for the patient's outcome and you are paid appropriately for your services. 

Residency is as brutal as it is because of $$$. Residents are cheaper than attendings or even NPs and can't leave if the workplace is toxic. 

This is why i hate the match. It is anticompetitive. Once a resident is in a program they are the program's plaything without recourse. The program makes money off residents as half of the GME allowance goes directly to the program, and the government saves money by not having to pay attendings or NPs to cover call or wards. 

In the old days docs had a bit more power over this as they could just quit, or change programs, if the one they were at was not working out.

This is why the rotating internship model was good. It was flexible. There is no argument against it now that nurses and pharmacists are practicing primary care independently.

I swear if I was allowed to bill even 10% of the dollar amount for the billing codes for each patient, I'd be a much more motivated worker...it's sometimes not even about the amount of money, it's about the feeling of knowing there is scalable reward for my effort.

[indefatigable]

11 hours ago, GrouchoMarx said:

The stamina argument is poor. Its easy to find the stamina to do medicine at any hour for as long as possible if you are the one responsible for the patient's outcome and you are paid appropriately for your services.

Residency is as brutal as it is because of $$$. Residents are cheaper than attendings or even NPs and can't leave if the workplace is toxic.

This is why i hate the match. It is anticompetitive. Once a resident is in a program they are the program's plaything without recourse. The program makes money off residents as half of the GME allowance goes directly to the program, and the government saves money by not having to pay attendings or NPs to cover call or wards.

In the old days docs had a bit more power over this as they could just quit, or change programs, if the one they were at was not working out.

This is why the rotating internship model was good. It was flexible. There is no argument against it now that nurses and pharmacists are practicing primary care independently.

Many in the CFPC want to add an extra-year to FM training, like in the US, as it could be helpful in today's more medically complex environment with competing mid-levels and increased medico-legal risk.  So it's wishful thinking to imagine that a full-general licensure would be brought back after a single rotating-internship year.

Let's say some kind of limited-license granting rotating internship was brought back, without a full license as the CFPC wouldn't agree to that - then at least half the interns would be trying to get into whatever specialty they want, arranging electives, doing research and getting letters, and would have less experience compared to the past (as clerkship doesn't seem to have the same demands as back in the day).  So gunning for specialties would be very similar, but an even longer multiyear campaign.  Many of the interns would be unevenly trained because of the competing career directions and might have to extend their subsequent specialty training which would decrease their satisfaction with the model.    

Afterwards, the interns would end up with some sort of limited license, maybe with different billing codes, etc, and there'd be two class of physicians - those that go onto "full license" and those that stay limited-license practitioners.  One could imagine the government would seize the opportunity to limit the "full license" physicians to cut costs and fill rural areas.

I doubt the non full-license CMGs, with high debt loads, would be much better off.  Plus - all of a sudden many Canadian docs would look amateur and maybe worse compared to other health professionals as well as compared to 4+3-year US-trained FM docs.  Not to imagine the huge headache to add the extra-year either into med school or a pre-CaRMs year(s).

I'm not saying more flexibility isn't a good thing and there could be better incentives within the system, but programs don't want to lose out on their investment because of a change of direction.  I think allowing for more re-entry for licensed physicians could also overall increase productivity and job satisfaction.

As I've mentioned before, increased elective diversity and having better clerkship structure accomplishes many of the same goals of the rotating internship.  As the general licensure is highly unlikely to be brought back with only an additional year, creating a class of limited-license physicians may be even worse.  

[GrouchoMarx]

1 hour ago, tere said:

Many in the CCFP want to add an extra-year to FM training, like in the US, as it could be helpful in today's more medically complex environment with competing mid-levels and increased medico-legal risk.  So it's wishful thinking to imagine that a full-general licensure would be brought back after a single rotating-internship year.

Let's say some kind of limited-license granting rotating internship was brought back, without a full license as the CCFP wouldn't agree to that - then at least half the interns would be trying to get into whatever specialty they want, arranging electives, doing research and getting letters, and would have less experience compared to the past (as clerkship doesn't seem to have the same demands as back in the day).  So gunning for specialties would be very similar, but an even longer multiyear campaign.  Many of the interns would be unevenly trained because of the competing career directions and might have to extend their subsequent specialty training which would decrease their satisfaction with the model.    

Afterwards, the interns would end up with some sort of limited license, maybe with different billing codes, etc, and there'd be two class of physicians - those that go onto "full license" and those that stay limited-license practitioners.  One could imagine the government would seize the opportunity to limit the "full license" physicians to cut costs and fill rural areas.

I doubt the non full-license CMGs, with high debt loads, would be much better off.  Plus - all of a sudden many Canadian docs would look amateur and maybe worse compared to other health professionals as well as compared to 4+3-year US-trained FM docs.  Not to imagine the huge headache to add the extra-year either into med school or a pre-CaRMs year(s).

I'm not saying more flexibility isn't a good thing and there could be better incentives within the system, but programs don't want to lose out on their investment because of a change of direction.  I think allowing for more re-entry for licensed physicians could also overall increase productivity and job satisfaction.

As I've mentioned before, increased elective diversity and having better clerkship structure accomplishes many of the same goals of the rotating internship.  As the general licensure is highly unlikely to be brought back with only an additional year, creating a class of limited-license physicians may be even worse.  

An apprenticeship model after an internship would function far more effectively than a family medicine residency program. Work with a mentor and collect 50% of billings.

I am against adding a third year, as it is unnecessary. Adding the second year was equally unnecessary. The main thing it accomplishes is providing the government with a few years of highly skilled doctor labor at a fraction of the cost. That's probably one of the reasons why the CFPC was successful in pushing the exclusivity of family medicine - it is overall a cheaper proposition for the government.

I think residency programs overall are self-aggrandizing their importance in the grand scheme of producing competent physicians, as recruitment standards for unpopular fields are incredibly relaxed. Taking on better people would make better doctors. Most programs are too long to account for this discrepancy. Pathology is certainly too long and could be done in four, including an internship.

[indefatigable]

3 hours ago, GrouchoMarx said:

An apprenticeship model after an internship would function far more effectively than a family medicine residency program. Work with a mentor and collect 50% of billings.

I am against adding a third year, as it is unnecessary. Adding the second year was equally unnecessary. The main thing it accomplishes is providing the government with a few years of highly skilled doctor labor at a fraction of the cost. That's probably one of the reasons why the CFPC was successful in pushing the exclusivity of family medicine - it is overall a cheaper proposition for the government.

I think residency programs overall are self-aggrandizing their importance in the grand scheme of producing competent physicians, as recruitment standards for unpopular fields are incredibly relaxed. Taking on better people would make better doctors. Most programs are too long to account for this discrepancy. Pathology is certainly too long and could be done in four, including an internship.

Forgetting the political issues for an instance -  what would be the point of the apprenticeship after a full-license?  If not a full-license, how long it would take to get one  - mentor dependent? 

Having an informal mentor is similar, but different than being an apprentice.  What would be the motivation for a mentor to give away half of their billings and incur medico-legal or at least reputation risk?  All the studies that I've seen suggest better outcomes with 2-year CCFP vs general licensure.

[blah1234]

14 hours ago, GrouchoMarx said:

The stamina argument is poor. Its easy to find the stamina to do medicine at any hour for as long as possible if you are the one responsible for the patient's outcome and you are paid appropriately for your services.

Residency is as brutal as it is because of $$$. Residents are cheaper than attendings or even NPs and can't leave if the workplace is toxic.

This is why i hate the match. It is anticompetitive. Once a resident is in a program they are the program's plaything without recourse. The program makes money off residents as half of the GME allowance goes directly to the program, and the government saves money by not having to pay attendings or NPs to cover call or wards.

In the old days docs had a bit more power over this as they could just quit, or change programs, if the one they were at was not working out.

This is why the rotating internship model was good. It was flexible. There is no argument against it now that nurses and pharmacists are practicing primary care independently.

I find that I'm doing long hours now because of coverage requirements. The staff billing isn't enough for me to take pages whenever they arise. If I can push it to the morning I will. I think the money is a nice change of pace compared to residency but I think the comfort I have juggling multiple sick patients while being exhausted was something I learned how to do during residency. If you threw staff billings at my resident self I'm sure it would've been nice but I'm not sure I would've made good medical decisions being fatigued and inexperienced. While residency is brutal because we are underpaid I think there is a huge component of being unskilled. I just wasn't as fast, knowledgeable, or steadfast back then compared to now. Even with all the scut and nonsense if I went back I could probably do all my rotations with way less effort.