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5 hours ago, Aetherus said:

I agree that there is no metric that would point towards 3 year graduates doing worse in these situations. 
My main concern is that I think our current system is failing to educate clinicians on the basics for many specialities and that a 4 year program has more room to try and improve the situation. This also is way I am against letting students focus on what they think is important for their future career goals as I don’t think medical students have the required perspective to make those choices.

I agree that 3 year programs should either become boot camp like, traditional teaching programs or become a 4 year program. PBL and 3 year program does not mix. 

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8 hours ago, Aetherus said:

I agree that there is no metric that would point towards 3 year graduates doing worse in these situations. 
My main concern is that I think our current system is failing to educate clinicians on the basics for many specialities and that a 4 year program has more room to try and improve the situation. This also is way I am against letting students focus on what they think is important for their future career goals as I don’t think medical students have the required perspective to make those choices.

I think the answer for this, and for anyone else frustrated with deficiencies in the medical school system, is to get involved with the medical schools and advocate for curriculum standards, and work with them and decide what is an appropriate medical school competency vs residency. I do think self directed learning is better than the traditional style, but if you're concerned that students are missing a vital aspect, then formalize it.

5 hours ago, indefatigable said:

Anatomy teaching is a great example since it's been an area where some schools have chosen to continue to emphasize traditional dissection whereas others have almost abandoned cadavers entirely.  No one disputes that learning detailed anatomy is essential for surgery; but the importance of anatomy is for the rest of medicine elicits different opinions/perspectives. 

There is pretty good evidence that prosections are equivalent, if not superior to dissections for learning anatomy. No idea if dissections are better for learning surgical technique, but probably higher yield to actually assist in surgeries for that.

And when it comes to learning embryology/pathology/histology/biochemistry, the yield of each is highly variable. I would argue that the vast majority is not helpful for most medical students, and if one aspect is relevant, the others are not. I agree with having a reasonable foundation, and understanding branchial cleft formation would be very helpful for an ENT I suspect, but as a pediatrician I really just know that sometimes congenital cysts form in them. Similarly an understanding of aortic arch formation will reveal the origin of coarctations and PDAs but are not relevant in the day to day. I am sincerely glad that, unlike American medical school which teaches to the steps, what I feel to be low-yield information, MD in Canada at least attempts to teach to actual practice.

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9 hours ago, bearded frog said:

There is pretty good evidence that prosections are equivalent, if not superior to dissections for learning anatomy. No idea if dissections are better for learning surgical technique, but probably higher yield to actually assist in surgeries for that.

And when it comes to learning embryology/pathology/histology/biochemistry, the yield of each is highly variable. I would argue that the vast majority is not helpful for most medical students, and if one aspect is relevant, the others are not. I agree with having a reasonable foundation, and understanding branchial cleft formation would be very helpful for an ENT I suspect, but as a pediatrician I really just know that sometimes congenital cysts form in them. Similarly an understanding of aortic arch formation will reveal the origin of coarctations and PDAs but are not relevant in the day to day. I am sincerely glad that, unlike American medical school which teaches to the steps, what I feel to be low-yield information, MD in Canada at least attempts to teach to actual practice.

It wasn't so much the technique (i.e. prosection vs dissection), it was more about the time.  I'm sure on a unit by unit time measure, prosection may indeed be better for learning anatomy - but spending orders of magnitude more time on anatomy through longitudinal dissection probably leads to a better understanding and may (or may not) foster and interest in surgery.  Like I mentioned UofT has disproportionately more graduates that rank surgery first as compared to Mac - is this independent of the highly significant differences in time/technique/lab devoted to anatomy through prosection/dissection? 

My point was that there actually a lot of "low yield" information taught (or expected to learn) in the PBL curriculum  that I went through too - it was just different  flavour of "low yield".  Molecular minutiae were also gone over in detail - the problem was also that often there wasn't always that much clinical correlation (hours and hours per tutorial on concept maps which were immediately forgotten - this was dropped in the curricular renewal fortunately).  Plenty of pathophysiology that would be at best be dubious value/relevance to a sub-specialized internist.  

And sometimes the "practical" information was of quesionable value - hundreds/thousands of old articles/chapters on "practical" concepts which I never saw throughout clerkship (e.g. outdated orthopedic concepts/treatments while neglecting improving radiological interpretation for instance).   At the same time, basic ophthalmology was not taught until right before the MCCQE1 (and dermatology not much earlier).           

When clerkship arrived, people hadn't learned that much applied pharmacology (e.g. drug names/classes/mechanisms) despite having spent over two years in pre-clerkship.  Sometimes I actually thought some Step 1 material was more "high yield" - a significant part of that test is applied pharmacology.  But like I said earlier (and gave examples of earlier), I don't think much of that material is actually useful either.  And given the limited utility of most Step 1 material it definitely makes sense to de-emphasize it which is now occurring with the P/F transition in the US.  Still given the two plus years in pre-clerkship, I found it ironic how embryology was essentially barely touched on given that it has some clinical correlation and I personally thought helpful for understanding.  Step 2 is a very different test and much closer to the desired "clinical concepts".  

Actually, Peds was considered a strength at the school that I went to.  While I personally found the French language more of an issue during my clerkship exposure, I recognize that there was a strong tradition - I remember being "pimped" on naming and describing the pathophysiology of the risk factors of DDH as well detailing a differential diagnosis of toe walking (areas I had learned on my own outside of pre-clerkship however).  At least one two preceptors at McGill commented on the strength of the pediatric residents from the school that I went to..  That sort of stuff isn’t on any Step exam and to be honest I thought was much more resident level - I recognized however the high standards (although I also had the oldest of "old school" as evaluators).

I'm not advocating for any particular system - just noting that there's a tendency to avoid discussing differences or areas of improvement or look at inefficiencies in the system.  

As I mentioned, even within Canada, there are very significant documented differences in learning/exposure both during pre-clerkship and clerkship.  All approaches may yield an "equivalent degree", but they are not “equal”.   These differences may (or may not) lead to better foundation and may (or may not) be more efficient.  Like I said earlier, people will tend to figure it out, despite whatever deficiencies exist - that doesn't mean that there can't be improvement.

I believe that we should be open to questioning and critiquing - to me that's a sign of a healthy system.  

9 hours ago, bearded frog said:

I think the answer for this, and for anyone else frustrated with deficiencies in the medical school system, is to get involved with the medical schools and advocate for curriculum standards, and work with them and decide what is an appropriate medical school competency vs residency. I do think self directed learning is better than the traditional style, but if you're concerned that students are missing a vital aspect, then formalize it.

I tend to believe the "status quo" is more or less set wherever one is and at best incremental change can occur - for instance dropping the requirement of concept maps each tutorial at my school's curriculum which was finally recognized to be an inefficient way to learn.  Practically speaking it's very hard to do a "radical rethink" when everything is set up in a certain way.  Plus, many people have a very different opinion so often the most entrenched interests get their way.  

I also think PBL was very much "faculty directed" rather than "self directed", but more "self paced".  I don't think either extreme of PBL or traditional is ideal (my school was almost entirely PBL), but probably somewhere in the middle.  I tend to find that in discussions people get polarized or defensive when it comes to recognizing weaknesses/strengths of their or other approaches. 

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9 hours ago, bearded frog said:

I think the answer for this, and for anyone else frustrated with deficiencies in the medical school system, is to get involved with the medical schools and advocate for curriculum standards, and work with them and decide what is an appropriate medical school competency vs residency. I do think self directed learning is better than the traditional style, but if you're concerned that students are missing a vital aspect, then formalize it.

There is pretty good evidence that prosections are equivalent, if not superior to dissections for learning anatomy. No idea if dissections are better for learning surgical technique, but probably higher yield to actually assist in surgeries for that.

And when it comes to learning embryology/pathology/histology/biochemistry, the yield of each is highly variable. I would argue that the vast majority is not helpful for most medical students, and if one aspect is relevant, the others are not. I agree with having a reasonable foundation, and understanding branchial cleft formation would be very helpful for an ENT I suspect, but as a pediatrician I really just know that sometimes congenital cysts form in them. Similarly an understanding of aortic arch formation will reveal the origin of coarctations and PDAs but are not relevant in the day to day. I am sincerely glad that, unlike American medical school which teaches to the steps, what I feel to be low-yield information, MD in Canada at least attempts to teach to actual practice.

I have been involved in teaching and medical curriculum design for my specialty from very early on. Unfortunately, just because you feel the curriculum needs an overhaul doesn’t mean that someone else values the status quo. As a resident you have limited power in this regard aside from volunteering your time. Further more, I think there is significant bias in what gets taught based on other factors influencing the curriculum. At my school we had 6 weeks course on OBGYN and 6 weeks of clerkship. 6 weeks of PSYCH in preclerkship and 6 weeks in clerkship. ENT, DERM, OPHTHO got 2 weeks combined (which is higher than average I believe but still abysmal). There is no justification in my opinion to neglect these specialties. 20% if primary care complaints are dermatology related. Why would we not learn more Derm? Everyone needs to be able to look at scans and get the radiology teaching we got was a few days scattered in preclerkship. I feel the curriculum is often time politically motivated towards things that are hot in the media (women’s health, mental health etc) which are obviously very important, but not necessary at the expense of even basic teaching in other disciplines.

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1 hour ago, Aetherus said:

20% if primary care complaints are dermatology related.

Because the dermatologists don't want to teach anyone so that they can hold provincial governments at gunpoint. They don't want anyone else knowing anything about their specialty and encroaching on their turf. Dermatologists are probably the most turf controlling of all specialists.

Derm referrals have the longest median wait time of all specialties in Ontario, yet there are only six Derm spots in a province of 14.5 million. @indefatigable linked to how they explicitly mentioned limiting spots to keep their job market great and not letting FMs learn basic Derm as to not confuse the public.

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5 hours ago, zoxy said:

Because the dermatologists don't want to teach anyone so that they can hold provincial governments at gunpoint. They don't want anyone else knowing anything about their specialty and encroaching on their turf. Dermatologists are probably the most turf controlling of all specialists.

Derm referrals have the longest median wait time of all specialties in Ontario, yet there are only six Derm spots in a province of 14.5 million. @indefatigable linked to how they explicitly mentioned limiting spots to keep their job market great and not letting FMs learn basic Derm as to not confuse the public.

@zoxy correctly initially inferred that the objection to added FM competency in derm was seemingly driven by the lucractive cosmetic market and turf  - rather than concerns of dermatological care for underserved patients/populations despite very few training spots.  

Paradoxically, or perhaps because of the additional training given to students, BC dermatologists do earn less than their counterparts in other provinces.  Derm in AB/MB esp. and NB/NL is almost ridiculously lucrative - perhaps some may fear the BC model.

 

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6 hours ago, indefatigable said:

It wasn't so much the technique (i.e. prosection vs dissection), it was more about the time.  I'm sure on a unit by unit time measure, prosection may indeed be better for learning anatomy - but spending orders of magnitude more time on anatomy through longitudinal dissection probably leads to a better understanding and may (or may not) foster and interest in surgery.  Like I mentioned UofT has disproportionately more graduates that rank surgery first as compared to Mac - is this independent of the highly significant differences in time/technique/lab devoted to anatomy through prosection/dissection?

I, personally, would be frustrated if we had more mandated anatomy lab time. I learned better from anatomy atlases and videos than grey cadavers. Mac's anatomy educators consistently won awards for their teaching, but the amount of time you spent in the lab was up to you, we had specific times to go but you could go any other time you liked if that worked for you.

I am very skeptical of the claim that Toronto has more surgery applicants than Mac due to time spent in the anatomy lab. You posted some CaRMS data from 2019 and 2020 earlier which showed higher surgical applicants at U of T vs Mac, however you did not account for the 20% more applicants at U of T.

I went back over the last 5 years to see how many CaRMS applicants from each school applied to surgical subspecialities as a proportion of the total class, a much better measure. As you can see from the following graph, U of T certainly does have a higher proportion of surgical applicants, but to a fairly small relative degree. 2019 was an outlier at 7% more U of T applicants vs Mac choosing surgery, immediately followed by only 2% more in 2020. The average difference over the last 5 years was 4% more U of T applicants choosing surgery compared to Mac applicants.

bGPKeoA.png

I strongly suspect that this small but consistent increased proportion of applicants is multi-factorial, and not due to differences in anatomy teaching. Why? A study published last month using a Canadian national survey of surgical residents on the impact of anatomy teaching on their desire to choose a surgical specialty had no statistical difference between anatomy with dissection or not.

2 hours ago, Aetherus said:

I have been involved in teaching and medical curriculum design for my specialty from very early on. Unfortunately, just because you feel the curriculum needs an overhaul doesn’t mean that someone else values the status quo. As a resident you have limited power in this regard aside from volunteering your time.

100%. We have to play the long game, get involved in academic medicine upon completion of residency, join and be active in your specialty association, reach out to your local medical school to be involved with curriculum planning. Just as you say, things change painfully slowly, but the only way to overcome the status quo is to get to positions where you have the ability to do something about it.

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Hi everyone! I really appreciate this discussion but it's not what I had in mind when I created this forum.

If possible, I would appreciate if this conversation could be taken to a different posting. I feel like new medical students are already overwhelmed by the barrage of information thrown their way and the conversations in this forum can be quite overwhelming and intimidating for them. 

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12 minutes ago, MDIA said:

Hi everyone! I really appreciate this discussion but it's not what I had in mind when I created this forum.

If possible, I would appreciate if this conversation could be taken to a different posting. I feel like new medical students are already overwhelmed by the barrage of information thrown their way and the conversations in this forum can be quite overwhelming and intimidating for them. 

There's a bit of a tangent about what should be required curriculum in every medical school, but there is a fairly important discussion about if potential applicants should hesitate to attend a 3 year school like Mac over a 4 year school going on. (They shouldn't :p)

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4 hours ago, bearded frog said:

I, personally, would be frustrated if we had more mandated anatomy lab time. I learned better from anatomy atlases and videos than grey cadavers. Mac's anatomy educators consistently won awards for their teaching, but the amount of time you spent in the lab was up to you, we had specific times to go but you could go any other time you liked if that worked for you.

I am very skeptical of the claim that Toronto has more surgery applicants than Mac due to time spent in the anatomy lab. You posted some CaRMS data from 2019 and 2020 earlier which showed higher surgical applicants at U of T vs Mac, however you did not account for the 20% more applicants at U of T.

I went back over the last 5 years to see how many CaRMS applicants from each school applied to surgical subspecialities as a proportion of the total class, a much better measure. As you can see from the following graph, U of T certainly does have a higher proportion of surgical applicants, but to a fairly small relative degree. 2019 was an outlier at 7% more U of T applicants vs Mac choosing surgery, immediately followed by only 2% more in 2020. The average difference over the last 5 years was 4% more U of T applicants choosing surgery compared to Mac applicants.

bGPKeoA.png

I strongly suspect that this small but consistent increased proportion of applicants is multi-factorial, and not due to differences in anatomy teaching. Why? A study published last month using a Canadian national survey of surgical residents on the impact of anatomy teaching on their desire to choose a surgical specialty had no statistical difference between anatomy with dissection or not.

I appreciate that you went back and spent some time looking into this one issue.  While it was only one of many broad points I was making, I am glad that you have indeed graphically demonstrated that there is in fact a very significant difference between UofT and Mac with respect to Surgery applications to CaRMS and validated my point.  

Descriptive statistics is interesting as how the data is presented is sometimes as important as what is presented.  Certainly, I agree that taking into account class size makes good sense - however, presenting the data as relative fractions does not clearly show the differences between the two schools as it is the relative rather than absolute differences which really stand out (which are influenced by the majority of non-surgical disciplines).  

While you now concede that there are differences between both schools, you disagree that the method/time spent teaching has any influence on choice towards surgery and point out an article to bolster your argument.  

It's a good idea when people try to look into this, but given the incredibly small response rate (15%), even small sample sizes in most of the disciplines and I'm not sure whether it's something I would hang my hat on.  Plus, given the post-hoc nature of the questionnaire, I think it's really hard to draw firm conclusions.  

Within the article itself there seems to be some supportive evidence that dissection was actually a positive or even determining influence:

e.g. "Comments regarding cadaveric dissection in particular were positive overall, with 3 respondents highlighting its importance in encouraging pursuit of a surgical specialty."

"In particular, the CaRMS decisions of general surgery and orthopedic surgery residents were more influenced by their experience with UGME anatomy training than by other factors   General surgery residents were more heavily influenced than other surgical residents by UGME anatomy training with cadaveric dissection." 

You use the term "multifactorial" but seem to deny that anatomy exposure could have any influence.  

But, regardless, I think part of my goal was awareness of differences and I hope that people can better make informed choices or understand perhaps the differences that they will be faced with.  

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3 hours ago, bearded frog said:

There's a bit of a tangent about what should be required curriculum in every medical school, but there is a fairly important discussion about if potential applicants should hesitate to attend a 3 year school like Mac over a 4 year school going on. (They shouldn't :p)

I agree. Although the conversation is slightly tangential, I believe that the points made in this thread paint a good picture of the various opinions and points of consideration when selecting a 3 vs 4 year school.

3 hours ago, MDIA said:

Hi everyone! I really appreciate this discussion but it's not what I had in mind when I created this forum.

If possible, I would appreciate if this conversation could be taken to a different posting. I feel like new medical students are already overwhelmed by the barrage of information thrown their way and the conversations in this forum can be quite overwhelming and intimidating for them. 

I understand your perspective but I think this is important information for people to consider now to make an informed decision. I think this thread has actually been fairly balanced in terms of discussing the various factors that are at play in applicants medical studies. While possibly intimidating, I think this information is important in the decision making of students.

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7 hours ago, indefatigable said:

Descriptive statistics is interesting as how the data is presented is sometimes as important as what is presented.  Certainly, I agree that taking into account class size makes good sense - however, presenting the data as relative fractions does not clearly show the differences between the two schools as it is the relative rather than absolute differences which really stand out (which are influenced by the majority of non-surgical disciplines). 

Are you suggesting that relative numbers are not appropriate here? When class sizes vary you can't just take the total numbers, or else you obviously will come to the wrong conclusions, as demonstrated when you compare the raw number of applicants in 2020 to non-surgical specialties from each school: 216 for U of T and 171 for McMaster. Based on these numbers it's extremely clear that McMaster must have more dedication to surgery or else why would U of T have so many not interested in surgery? :rolleyes:

Anyways, I do agree that Toronto does have a very small, consistent, increased proportion of surgical applicants. I have my own theories about why that might be, without anyway to test them, including things like applicant self-selection, what strengths each school looks at in admissions and how that may correlate to desired specialty, etc. The data that I could easily see, as I posted above, seems to suggest other facets of anatomy education play a larger role than cadavers vs prosections. In any case it's not my paper and for further consideration of the issue, people who have thought about it way more than me have debated it pretty thoroughly more than 15 years ago.

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13 hours ago, bearded frog said:

Are you suggesting that relative numbers are not appropriate here? When class sizes vary you can't just take the total numbers, or else you obviously will come to the wrong conclusions, as demonstrated when you compare the raw number of applicants in 2020 to non-surgical specialties from each school: 216 for U of T and 171 for McMaster. Based on these numbers it's extremely clear that McMaster must have more dedication to surgery or else why would U of T have so many not interested in surgery? :rolleyes:

Anyways, I do agree that Toronto does have a very small, consistent, increased proportion of surgical applicants. I have my own theories about why that might be, without anyway to test them, including things like applicant self-selection, what strengths each school looks at in admissions and how that may correlate to desired specialty, etc. The data that I could easily see, as I posted above, seems to suggest other facets of anatomy education play a larger role than cadavers vs prosections. In any case it's not my paper and for further consideration of the issue, people who have thought about it way more than me have debated it pretty thoroughly more than 15 years ago.

Descriptive statistics involves a lot of choices - choosing axis, scale, etc.. the classic text is "How to Lie With Statistics" - https://en.wikipedia.org/wiki/How_to_Lie_with_Statistics.  I think your scale is ok, but the bars have limited interpretation, and you graph doesn't take into account the varying number of participants per year.

Total class size is not actually not a great reference here  as it doesn't take into account previously unmatched students, etc...  I am not sure where you took your data from, but I went back and looked at both the total match participation and the number of students that ranked surgery first for each of those two schools (Tables 2 and 36 for the CaRMS data).  In 2018, for instance Mac had 224 participants in the first round of CaRMS including 13 prior year graduates and 211 "current year" graduates.  Likewise, in 2016, there were 12 prior year graduates.  

For each of those years, I went back and calculated the odds ratio comparing exposure to the UofT environment vs Mac with ranking surgery first.  The odds ratio is nice because it doesn't depend on scale or axis choice and it accounts for the differences in varying match participants.  Plus, it has a familiar interpretation.  In this case, the increased odds of ranking surgery first for UofT vs Mac CaRMS applicants ranges from about 20% to 80% (~1.2 to ~1.8).  

OddsRatio.jpg

Finally, to me the older articles that you posted don't answer the central question of explaining the difference between UofT and Mac with respect to surgery ranking.  I found the passages that I highlighted more insightful and they were independently concordant with intuition. 

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12 hours ago, indefatigable said:

I think your scale is ok, but the bars have limited interpretation, and you graph doesn't take into account the varying number of participants per year.

Using a percentage of total applicants explicitly accounts for the varying class sizes both between each school and among each year. If 50 people apply each year for two years in a row, but there was 100 participation one year and 200 the next, that's an extremely significant change that you wouldn't get from the raw numbers. the graph is a percentage/ratio of surgery applicants to total applicants for each year, and so will account for the different class size at U of T and the changing applicant pool over the years.

12 hours ago, indefatigable said:

Total class size is not actually not a great reference here  as it doesn't take into account previously unmatched students, etc...  I am not sure where you took your data from, but I went back and looked at both the total match participation and the number of students that ranked surgery first for each of those two schools (Tables 2 and 36 for the CaRMS data).  In 2018, for instance Mac had 224 participants in the first round of CaRMS including 13 prior year graduates and 211 "current year" graduates.  Likewise, in 2016, there were 12 prior year graduates. 

I didn't use class size, I used the data you describe here, the final match participation based on table 6 from the carms data (which has the same "final participation" as table 2) and table 36 for applicant numbers. Since carms doesn't break out specialty applications between current year and prior year, we have to use total participation and not current year graduates to accurately use the specialty application data. Also current year graduates may include unmatched previous year applicants who defer graduation so there is no way to realistically just discuss first attempt applicants.

12 hours ago, indefatigable said:

For each of those years, I went back and calculated the odds ratio comparing exposure to the UofT environment vs Mac with ranking surgery first.  The odds ratio is nice because it doesn't depend on scale or axis choice and it accounts for the differences in varying match participants.

Using an odds ratio is a completely reasonable method of interpretation in this case, as it's basically what I did, jut a further step of dividing each percentage by each other to get a ratio. However, just like in medicine we need to remember the context of relative vs absolute outcomes, just like how having a febrile seizure doubles your lifetime risk of epilepsy, but that increases it only 1-2% lifetime risk overall. Also, if we use an odds ratio, we can then create a confidence interval to see if the results are statistically significant.

So, I have recreated your OR graph but included the confidence intervals.

sT6hTxM.png

Oops, the confidence intervals are so big it gets cut off, lets try again.

Up3khJn.png

As you can see, the CI for each individual data point crosses 1, except for in 2019, so that is the only year we can say is significant. However when you take total number of applicants and carms participants for each school in the last 5 years you get 17.5% average surgical applicants at U of T, and 13.4% average surgical applicants at Mac, which gives an OR of 1.31 and a 95% CI of 1.64 to 1.05, which crucially does (barely) stay above 1.

All that to say, I do not disagree that U of T does have a small but significant increased proportion of applicants who choose surgery first. We disagree to the degree that cadaver dissection has an effect in this difference. I have provided evidence that it does not seem to play a significant role, you have provided none to support your claim. I would suggest that the increased number of surgeons/surgeries in Toronto, as well as it being a national centre for more complex surgeries (In my world at least, Mac doesn't do pediatric cardiac surgery and patients go to Toronto instead), either causes students with the option who are gunning for surgery to self select to Toronto, or increased exposure in Toronto attracts more applicants, seems like a much more significant factor, among others, but again, without any objective data surveying applicants at each school, we cannot know for sure.

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6 hours ago, bearded frog said:

Using a percentage of total applicants explicitly accounts for the varying class sizes both between each school and among each year. If 50 people apply each year for two years in a row, but there was 100 participation one year and 200 the next, that's an extremely significant change that you wouldn't get from the raw numbers. the graph is a percentage/ratio of surgery applicants to total applicants for each year, and so will account for the different class size at U of T and the changing applicant pool over the years.

I didn't use class size, I used the data you describe here, the final match participation based on table 6 from the carms data (which has the same "final participation" as table 2) and table 36 for applicant numbers. Since carms doesn't break out specialty applications between current year and prior year, we have to use total participation and not current year graduates to accurately use the specialty application data. Also current year graduates may include unmatched previous year applicants who defer graduation so there is no way to realistically just discuss first attempt applicants.

Using an odds ratio is a completely reasonable method of interpretation in this case, as it's basically what I did, jut a further step of dividing each percentage by each other to get a ratio. However, just like in medicine we need to remember the context of relative vs absolute outcomes, just like how having a febrile seizure doubles your lifetime risk of epilepsy, but that increases it only 1-2% lifetime risk overall. Also, if we use an odds ratio, we can then create a confidence interval to see if the results are statistically significant.

So, I have recreated your OR graph but included the confidence intervals.

L2qPxJp.png

Oops, the confidence intervals are so big it gets cut off, lets try again.

EBUDQxg.png

As you can see, the CI for each individual data point crosses 1, so we can't say the result from any specific year is significant. However when you take total number of applicants and carms participants for each school in the last 5 years you get 17.5% average surgical applicants at U of T, and 13.4% average surgical applicants at Mac, which gives an OR of 1.31 and a 95% CI of 1.64 to 1.05, which crucially does (barely) stay above 1.

All that to say, I do not disagree that U of T does have a small but significant increased proportion of applicants who choose surgery first. We disagree to the degree that cadaver dissection has an effect in this difference. I have provided evidence that it does not seem to play a significant role, you have provided none to support your claim. I would suggest that the increased number of surgeons/surgeries in Toronto, as well as it being a national centre for more complex surgeries (In my world at least, Mac doesn't do pediatric cardiac surgery and patients go to Toronto instead), either causes students with the option who are gunning for surgery to self select to Toronto, or increased exposure in Toronto attracts more applicants, seems like a much more significant factor, among others, but again, without any objective data surveying applicants at each school, we cannot know for sure.

GRAPHING/STATISTICS

It's helpful to describe what data you are using -  terms that you have used like "total class" and  "class size" are imprecise and don't convey that you are considering total participation (which may include previous year graduates).  I can't read your mind and have no idea which tables you are using - that is why I wrote mine down and explicitly mentioned "total participation".   We both agree that the data isn't perfect- and I outlined those issues in my previous post.  

In fact, I think trying to get precise answers out of this kind of data is fraught with error - to me the key idea is the indication and trend.  It would take a carefully designed study to answer this question properly.  I hope that we can now both agree that the article you posted initially does not give a definitive answer.    

I am glad, however, that you see the value of trying to use the odds ratio, which you say is "completely reasonable" and even went a step further by trying to add confidence intervals.    

However, just superficially checking your graph - the values on your attempted OR graph are not the same as mine.

For 2019 alone - I have 57/255 for UofT and 29/204 for Mac.  

Note that miscalculating the OR by dividing these two ratios gives 1.57.  This appears to be the number you obtained both by the graph and by your description.  

It's a common elementary error and this would correspond to relative risk which can't be calculated here since the prevalence of surgery is more than rare so the OR and RR are NOT equivalent.  

Instead, one has to calculate the surgical and non-surgical preferences match preferences and use the odds ratio:

For 2019 that would be:

UofT: 57 (surgical) and 198 (non-surgical) and Mac: 29 (surgical) and 175 (surgical)

Calculating the OR properly as (57/198) / (29/175) gives the number on my OR graph, 1.74, with a 90% CI (1.15, 2.62) and a 95% CI (1.06, 2.84) - i.e. statistically significant difference.

https://www.cdc.gov/csels/dsepd/ss1978/lesson3/section5.html (calculation)

I expect pooling the data would result in even sharper confidence interval by increasing the sample size and the consistency of the trend.

CAUSATION

It seems that you are conceding there is a difference, between UofT and Mac with respect to ranking surgery however.  Without citing any studies you are giving some potential reasons why you believe this is the case.  None of them significantly involve anatomy exposure or teaching.  

You have pointed out some tangential articles which related to the educational philosophy of teaching by prosection, dissection and other methods which appear to be mostly qualitative and debated.  This does NOT give any indication or refutation of choosing surgery based on educational exposure, however.

Instead, you choose to disregard key passages in the only introduced study designed to even begin to look at this question.  I have copied and pasted them here.  Even in a very weakly responded survey, one can see that there is some evidence that UGME teaching of anatomy influenced career choice.  

e.g. "Comments regarding cadaveric dissection in particular were positive overall, with 3 respondents highlighting its importance in encouraging pursuit of a surgical specialty."

"In particular, the CaRMS decisions of general surgery and orthopedic surgery residents were more influenced by their experience with UGME anatomy training than by other factors   General surgery residents were more heavily influenced than other surgical residents by UGME anatomy training with cadaveric dissection." 

It's worth noting that general surgery residents were by far the highest responders and perhaps the only group that any meaningful conclusion could be drawn from.  

I personally am tired of debating this.  I think at this point people can just draw their own conclusions.  

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6 hours ago, indefatigable said:

Note that miscalculating the OR by dividing these two ratios gives 1.57.  This appears to be the number you obtained both by the graph and by your description. 

You are correct! My apologies and it has been quite a few years since I last did stats math. I have corrected my graphs above. You can see that the only real change doing the math properly (again, sorry) is that the outlier year of 2019 does have a statistically significant CI, as you say.

6 hours ago, indefatigable said:

I expect pooling the data would result in even sharper confidence interval by increasing the sample size and the consistency of the trend.

Correct, as I said in my previous post, when you pool the 5 years together (both properly and erroneously calculating, it turns out) the difference is statistically significant, and again, I readily acknowledge that a small but significant difference exists between the two schools in that regard.

6 hours ago, indefatigable said:

Without citing any studies you are giving some potential reasons why you believe this is the case.  None of them significantly involve anatomy exposure or teaching.  

Unfortunately, I can only provide hypothesis as there is no available data that looks at why Mac or U of T students choose surgery or not. I looked!

6 hours ago, indefatigable said:

Instead, you choose to disregard key passages in the only introduced study designed to even begin to look at this question.

Just to make sure we're on the same page, you're referring to this study "Influence of undergraduate medical education exposure to cadaveric dissection on choice of surgical specialty: a national survey of Canadian surgical residents". They surveyed 228 surgical residents and asked how various factors affected their choice of surgery on a 5 point likert scale. We can see the survey questions here. They specifically asked for a response to the question "My first choice discipline for CaRMS was influenced by [X]" and scored where 1 was strongly disagree, 3 was neutral, and 5 was strongly agree.

The statement "My first choice discipline for CaRMS was influenced by UGME experience with cadaveric dissection" got a score of 2.97, which is just on the "somewhat disagree" side of neutral. Even for gen surg with a 3.4 it's still in the neutral range. The influence of anatomy teaching in general was less at 2.87.

Contrast this with "Experiences during surgery core rotation in clerkship" at 4.3, between somewhat and strongly agree, and "Experiences during an elective in a surgical specialty during clerkship" at 4.31 and "Mentor(s)" at 4.06, which were much more significant. These results seem to refute the value of dissection on the choice to pursue surgery, as you claim, and support the value of clerkship experience and mentorship, which is what I would suggest is more important.

You draw attention to specific passages:

7 hours ago, indefatigable said:

"Comments regarding cadaveric dissection in particular were positive overall, with 3 respondents highlighting its importance in encouraging pursuit of a surgical specialty."

It does seem that the respondents who had dissection enjoyed it, and the majority found it had the greatest impact on their anatomy learning. However only 3 of 228 students reported it being important in their desire to choose surgery does do much to advocate for this to be a prevalent position of the respondents. Illustrative comments regarding dissection in the paper have both positive and negative comments about it.

7 hours ago, indefatigable said:

"In particular, the CaRMS decisions of general surgery and orthopedic surgery residents were more influenced by their experience with UGME anatomy training than by other factors   General surgery residents were more heavily influenced than other surgical residents by UGME anatomy training with cadaveric dissection."

Looking at the data these comments are based on (Table 4) we see that the statement is relative. They were more influenced at "neutral" than other factors which they somewhat or strongly disagreed with. Gen surg residents indeed had a higher score with dissection, as I said above at 3.4, which is still closest to "neutral", compared to ortho which closest to "somewhat disagree" at 2.44, and other which was neutral at 2.73.

7 hours ago, indefatigable said:

I personally am tired of debating this.  I think at this point people can just draw their own conclusions.  

Fair enough. I have presented evidence that the small increased proportion of surgical applicants at U of T compared to McMaster is likely not due to differences in anatomy teaching, and clerkship experience and mentorship is much more significant. I would suspect that the difference is therefore due to increased surgical exposure and mentorship at U of T, due to them being a larger and highly specialized national referral centre. People can indeed draw their conclusions.

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My two cents is that I did both dissection in undergrad and prosection at Mac and the anatomy curriculum at Mac was woeful. The prosected specimens were damaged and dried out and structures weren't identifiable. We spent a rushed 1 hour running through chest x-rays in MF1 and that was the end of CXR teaching until a brief teaching in the IM core clerkship.

What I was most disappointed with was that the anatomy lab spent more time and effort teaching non-MD students and undergrads than MD students. Taking the optional dissection course at Mac meant you went in a lottery with all health professional students and 1 in 4 got the lottery, the course also overlapped with your tutorial sessions. Anatomy lab sessions were structured like a visit to a museum and the tests were ridiculously easy. Fortunately, anatomy is reasonably easy to learn on your own, but I would definitely not consider Mac's anatomy teaching to be adequate for any doctor let alone surgeons. 

I also had an issue with the LGS, now i don't know how this is like at other schools, but the content varied wildly from lecturer to lecturer and was not a solid grounding in what medical students needed to know. I remember in GI that no time was spent on physiology (gastrin, somatostatin etc) pathology or pharmacology but a whole lecture was spent on pediatric GI nutrition with specific emphasis on how breast milk doesn't contain iron. Hopefully things have changed.

Do any of these factors really make a difference? Probably not, medicine in practice in a high resource setting like Canada is increasingly easy and no longer requires much knowledge. Most pre-op decision making is solved with a CT/MRI or U/S, medical diagnoses are solved with pan-bloodwork. Physical exams are optional and if you have any issues call ICU/Rapid Response/CODE Blue/Consult service. Would I trust a Canadian doctor in a low resource setting? Definitely not. 

I do hope that McMaster improves these aspects of the curriculum though  

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5 hours ago, Edict said:

 I remember in GI that no time was spent on physiology (gastrin, somatostatin etc) pathology or pharmacology but a whole lecture was spent on pediatric GI nutrition with specific emphasis on how breast milk doesn't contain iron.

Serious question, which of these topics do you think is more useful and relevant to medical practice for the majority of Mac's students?

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1 hour ago, bearded frog said:

Serious question, which of these topics do you think is more useful and relevant to medical practice for the majority of Mac's students?

I'm still a lowly student so I could be wrong, but doesn't this line of reasoning end in we shouldn't teach anything in medical school since you'll learn everything you'll need to practice in residency? Just because something may not be 100% relevant in practice shouldn't mean we should not be teaching it.

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16 hours ago, zoxy said:

I'm still a lowly student so I could be wrong, but doesn't this line of reasoning end in we shouldn't teach anything in medical school since you'll learn everything you'll need to practice in residency? Just because something may not be 100% relevant in practice shouldn't mean we should not be teaching it.

I just wanted to point out that it was a weird example to use. His concerns that the didactic sessions were not helpful to him are completely valid - they weren't really to me either, and were optional so did not attend. I have no problems with lectures on both pediatric nutrition or gastrointestinal regulatory hormones. I just wanted to point out that infant nutrition is highly relevant for just under half of the class - those going to into FM and peds, and probably useful for any specialty that deals with children. In fact based on the amount of iron deficiency anemia that exists due to not introducing iron-rich foods at 6m or allowing too much milk to make up the majority of the diet as they get older, it probably was not emphasized enough. On the other hand, an understanding of the role of somatostatin is probably useful for GI or endocrine but doesn't come up a lot otherwise I imagine.

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12 hours ago, bearded frog said:

they weren't really to me either, and were optional so did not attend

FWIW the twice weekly pre-clerkship lectures are now mandatory (mine was the last class for which they were optional). I cannot speak to the quality or consistency of that quality though. I don't know what other school's are like, but the usefulness of lectures was very dependent on the lecturer at Mac.

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10 hours ago, Persephone said:

FWIW the twice weekly pre-clerkship lectures are now mandatory (mine was the last class for which they were optional). I cannot speak to the quality or consistency of that quality though. I don't know what other school's are like, but the usefulness of lectures was very dependent on the lecturer at Mac.

Wow... that's not great. I thought the whole point of Mac is that you can learn in your own way and to minimize didactic teaching as much as possible. (I understand procomp being mandatory though). Are they online at least?

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1 hour ago, bearded frog said:

Wow... that's not great. I thought the whole point of Mac is that you can learn in your own way and to minimize didactic teaching as much as possible. (I understand procomp being mandatory though). Are they online at least?

They are currently all held virtually since COVID. You have to watch synchronously though, there's an attendance password you have to enter online and are given at some point in the lecture.

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On 5/31/2021 at 1:02 AM, bearded frog said:

Serious question, which of these topics do you think is more useful and relevant to medical practice for the majority of Mac's students?

Definitely the basics, the reason? You don't learn it again. Everyone should have a basic understanding of GI anatomy, physiology, pathology and pharmacology. People use drugs like octreotide, maxeran, PPIs all the time, they ought to know why and how they work. 

You are meant to learn that breast milk doesn't contain iron in residency if you are going to be a family doctor or pediatrician (besides its not even that difficult to remember, you don't need to spend 3 hours on it). Residency is the time when you learn the practice relevant bits, building a house without a solid foundation is just building a generation of doctors who memorize rather than understand. 

Don't get me wrong, i'm not opposed to teaching the topic of peds GI nutrition, but when your LGS apparently don't teach any of the core, but spend 3 hours on a subtopic, I think that is wholly questionable. Maybe this lecture could be an optional upload online, but to spend 3 hours on that and then 3 hours on an IBD lecture and the differences between UC and Crohn's without first teaching them the anatomy and physiology of the GI tract is a recipe for lack of understanding. The examples don't end there though, the first cardiology lecture in MF1 was a talk that sped through all the boring arrhythmias like A-fib and A-flutter that any competent MS1 should know already, for the more relevant arrhythmias for the R4s in cardiology like AVRT, AVNRT, WPW, MAT, atrial tachycardia etc... oh wait..  

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