Changes are coming in residency training

The CMA posted this morning that residency expectations will be changed by 2017. It will be competency based  rather than time and exam based. In theory, this is already going on. You need to be recommended to sit your licensing exam by your program. If your program sees you as a resident at risk, they should not recommend you. From what I understand, this rarely happens, what Dr. Jason Frank in the article calls "failure to fail". Medicine in general has a tendency to pass students who should be re-mediated, or, kicked out. People are shocked that my school kicked 3 people out of our program, despite being a pass/fail school. So, sub-par residents can make it through to their exams missing essential skills.

My clerkship program was quite focused on our actions - for example, we all needed to deliver one baby vaginally, place 5 peripheral IVs, etc. etc. Students were not always able to complete the activities though because their residents scooped them all, their consultants didn't have time, or there just weren't enough patients. Fake signatures abounded, our teachers were willing to sign off when we were able to describe what we would do if given the opportunity. My exam in IM was meant to be hands on, but ended up being a  seated conversation between me and my preceptor.

In my experience, preceptors who are not in academic centers are not great teachers and can be even worse at giving feedback. Many I've met choose to stay away from academic centers to keep away from the extra workload of teaching and research. For residency programs to have such a strong focus on competency and the improvement of those competencies, there needs to be a significant improvement in the training of preceptors, especially those who are based in the community and in rural settings. 4 years is an optimistic turn over time. Many of the docs I've worked with this year are holding me to the same standards they were held to 15 years ago in their training in a specialty other than family medicine. Getting those docs into this decade, into my specialty, will take some effort. It will take much more to get them in line with an entirely new way of completing residency.

If however, this is based on objective observations by a small number of mentors/preceptors who can watch the resident progress from tadpole to frog, it will be a step in the right direction. These observers will need to have their own mentors to help them differentiate where a new resident should be versus a senior. The proposed evaluation program assumes that those evaluating residents will be able to make these distinctions. Unless you have experience with many residents at various levels, knowing how a resident is performing can be tricky.

Most concerning to me though, is the dependency of this type evaluation on numbers of patients. I've been worrying about this since I noticed the rising number of learners coming behind me while we are rushing patients out of hospitals. Despite taking on extra call shifts, totally ignoring PAIRO's rules about hours working, and leaving my cell number for all attendings to call me with juicy cases, at the end of my residency I have spaces in my skills log that are empty, experiences my residents told me I would get after clerkship. If I was graduating from residency in 2020 with the bad luck that I've had for catching cases that are on the relegated list of "must do's", it would take me extra time to finish. Which is fine. But it also means that I'd be taking those vaginal deliveries from junior residents and clerks, because shit does flow downhill.

In an ideal world, this is a great proposition. I try to be optimistic but  my experience with community docs having something extra to do makes it hard. I expect the community and rural programs to lose preceptors when their responsibilities change.

More from the rural hospital

Direct from my rural hospital cafeteria, Real Fruit! And yes that's a local strawberry.


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You may be working in a rural hospital if...

You may be working in a rural hospital if your cafeteria

• Is only open to the public between 11 and 2
• Makes real scones
• Serves the same lunch they serve the patients
• Is available 24/7 to all staff with a swipe card
• Lets you run a tab by writing down your eats on a sheet of paper
• Has employees that smile and call you by name

Making patients responsible for their own health

Something we talk about a lot at our hospital is that we expect our patients to take control of their own health.

You're out of breath and coughing like crazy? You should choose to stop smoking.

You've had a headache for three weeks and haven't tried Advil yet? Seriously? I have no words for you.

There are ads everywhere reminding patients that they need to be screened for various cancers. Patients should take responsibility for initiating contact.

Once you make contact, Advil didn't work or want to quit smoking? I'd LOVE to help. But honestly, if I'm pulling you by your nose to take care of yourself, you're not going to like it and I'm going to lose interest. Patients who come in wanting to find out what they can do to prevent constipation or to lower their cholesterol make me glow. I love teaching my patients.

An issue that comes up, as it does with so many patient centred practices, is time.

I try to get around this by building up an idea then giving my patients homework. Next visit, we review what happened. Getting patients to buy in is sometimes tricky but I find it gives us a goal to work towards in our visits, especially those with chronic disease.

I wonder if preparing a journal for patients with a specific disease to work through might work better. This article suggests journaling to improve compliance for exercise in the depressed, and offers suggestions for topics after walks such as "how do the trees around you look?" Maybe having a set list of mini goals to achieve would improve compliance.


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You might be a rural resident if...

You've used the phrase "the antibiotics I usually use for manure spreader injuries are..."

You need to avoid the horse plop when running between the clinic and hospital.

Your nurses are just nurses, not OR nurses and ER nurses and post surgical nurses. They do it all. And rock.

You ask all patients how they heat their homes and what kind of flooring they have. I have several patients who use wood exclusively to heat their homes and others with dirt flooring.

You've diagnosed ORF.

When screening for suicidality, checking for firearms in the home is a real concern. As is rope in the barn to hang from.

Your grocery buying habits have greatly improved because the store is full of your patients who are watching your cart.

Almost none of your patients are full code "I wouldn't treat my horse like that, why would I treat myself that way?".

You May Be Working in an Old OR

If this sign is posted ...


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Dealing with disappointment

Seeing so many of my colleagues get their first choice in the match this year made me excited for them. It also made me regret my decisions that let to me not getting my first choice of resident.

It was devastating last year when I didn't get my first choice, I tried to pretend I was happy with my placement but I truly wasn't. It took over a month to convince myself that residency, in a town I didn't want to be in, wouldn't suck.

I made my partner and I a home so we would be comfortable where we were going to live for (at least) the next 2 years. It's a comfy house that has a great patio in a nice neighbourhood. We're close to all amenities and less than 5 minutes from the hospital, perfect.

When I met my fellow residents, I was happy. This was as great group to be with.

My home base, a family health team, was welcoming and lovely. I felt like I was a part of the team.

But it still wasn't where I wanted to be.

This is why I did site visits in my first year of residency. No one that I know of was doing visits this year. I needed to remind myself of the happiness that was to come. It really helped keep me centered.

It also encouraged me to change the site I was at to one that would better suit my lifestyle and learning needs.

I start in a new town in July.




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Reason number 652 that rural medicine is more my cup of tea

Continuity. Even if I was working in the ED in small communities I found out what happened after they went home. In this city, I have no idea how my patients do after they leave my care. I don't know if my diagnosis was correct or if I made a mistake. I want to know how things go after the patient leaves the department.


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another reason rural hospitals are for me

no parking garages full of stressed out patients driving like idiots

they really try my patience every morning

Ranking

Starting during the CaRMS interview period, we are able to rank our programs but CaRMS doesn't lock in our choices until February 22nd. We can stew in our choices and make changes until then.

This is where the voodoo really starts.

CaRMS insists that the student is always the one who comes out on top and that they are able to match most students with their number one choice. Last year, 64.6% got their top choice, 2.9% got their 7th or lower.


Here’s how I see it happening for my friends applying to urban family.
Friend 1 wants to rank Mac - Hamilton, Mac - Brampton, UofT - urban, UWO - London, UWO - Regional (that’s it, he’s ballsy and only applied to 3 schools).

He is a good applicant, not stellar though, and will likely show up on each of the school’s rank lists unless he told one of his jokes in the interview, then God have mercy on his soul...
For this friend, having a pool of potential partners is more important than the program. Fair enough given that most family programs are essentially the same, it’s just the location that is remarkably different.
He will rank 1 - UofT, 2 - MH, 3. UL, 4. MB, 5. UR

When CaRMS goes to match him, they will first put him in the pool of people who picked UofT urban. There are 106 spots available for Canadian Medical Grads, so his odds are good. But if more than 106 people ranked UofT Urban first, my friend needs for UofT to have ranked him higher than a bunch of the others applying. If he is ranked 120 and UofT gets to their 150 spot of applicants, he’s in. If UofT only gets to 110, my friend goes to his second choice instead.

Here’s how it happens with me applying to my many (many) rural programs. Because the rural programs are so small, it may be easier to understand. Also because they are so small, it’s absolutely terrifying for me.

I’m ranking 24 programs all together (at 6 different schools). My top 5 programs have 22 spots total. Very different from my friend’s top 5 which has almost 300.
A - 2 spots
B - 1 spot
C - 5 spots
D - 1 spot
E - 13 spots
So my top 5 programs span 2 schools who have ranked me. At the risk of sounding conceited, I’m a strong candidate. I’ve been to the conferences, done the FM research, sat on every FM committee I could plus all my usual extracurriculars. On the whole, not a sucky candidate. I’m hoping it’s good enough to make it into their top ten.

Program A has 4 people who, like me, are gunning for it and will definitely rank A as their #1. There may be more but my sources weren’t clear. If any 2 of the 4 rank higher than me, CaRMS will look at my number 2 spot. If I’m lucky, no one else will want B as number one and it will still be in the running. Then I’m competing against all others who have B as #2. If that school ranks me above all others with it as #2, I get B. If not, I’m moved on to C. And so on.

It’s easy to see that if this continues, given how small the rural programs are, I could potentially end up at my 24th choice.

The trick with the ranking though, is to ignore what the schools are going to do and rank the programs according to what you want. Easier with the big programs than the small in my opinion... The other trick is to only rank the programs you can honestly see yourself in. Even though I have a program ranked 24, it would still be a good program for me. It’s clearly not my favourite, but if sent there by my binding CaRMS contract, I’m OK with it.

There are some programs I’m just not ranking because I don’t want to be sent to them. Worst case scenario I’m sent to the 2nd iteration and start over again.

Rural Medicine is where I belong

I had the absolute best day yesterday. It started off with me being late. Nothing out of the ordinary. And I went to the wrong room. Also not out of the ordinary.

In the wrong room, the nurses prodded me with questions about me and my partner; generally tried to make me feel welcome.

Made it the OB rounds where I was supposed to be which was mildly boring but incredibly educational. I love being able to learn.

Then to the emergency department. It was a busy day - 4 ambulances, lots of walk in patients. We also had 4 admissions. Wackiness.

We've had a patient with inoperable gut cancer that was an "orphan" patient my preceptor picked up. She has been bleeding constantly since admission and suffering from melena and diarrhea. In gynecology, when a fibroid bleeds too much and the woman requires as many transfusions as my cancer patient does, we consider embolizing the arteries feeding the fibroid to kill it. I didn't understand why this hadn't been done yet so I asked my preceptor who told me to ask the specialist who gave me multiple reasons including "because we don't do it". That's fine he's the specialist not me. Through the week I helped the patient with edema, anemia, increasing food intake, decreasing diarrhea and generally feeling like she and her husband were part of the health care plan.

Last night we transferred our patient to a higher care centre. The specialist was on the phone with my preceptor and told him that they planned to try to embolize the tumour, to which my preceptor responded "oh, isn't that what my medical student suggested last week?". I love this preceptor.

The patient's husband went over the plan with me one last time before the transfer. He'd had a horribly stressful week which he had the nasty habit of taking out on me and the staff. He cried and gave me a big hug before leaving and thanked me for helping them through their week.

In the afternoon all doctors were asked to report to the delivery room ASAP. We ran down the hall and entered to find a shoulder dystocia that wasn't going well. Since so many doctors made it to the room, after the baby was out, I stood back and watched the baby resuscitation (which went well). Dad was also quite far against the wall. Mom was freaking out because baby wasn't doing very well yet. I told him, in my very firm, no nonsense voice, that it was his job to hold mom's hand and keep her calm. Which he did. And that was good.