Rural Medicine

What do being featured on a Canada Day Parade float, surviving a grizzly encounter, catching my first 35 lbs salmon, getting picked up by teenagers at a run down bar, pulling all nighters in the health clinic, and making the front page of the local news have in common?  Not much.  Except after these 4 weeks in my 1st clerkship rotation, I can say "been there, done that".

As I plunge deeper into my clerkship years, I'm thinking more and more about what I want to be when I grow up.  Rural family practice is definitely one of a kind and has kept me on my toes.  It wasn't uncommon for me to drive 2 hours to even more remote villages for the weekly clinics there.  There were days where I'd poke babies for their vaccines, K.O. an aggressive alcoholic, and several motor vehicle traumas all before being called back in for someone with heart failure that was being choppered in.  I was able to do the ER bit, but still have complete follow-up with the patients.  Pretty neat stuff that ain't served in the city. 

I can definitely see myself doing this for a living but rural is...well  rural.  I freaken love the idea of being a jack of all trades physician and have the ability to go fishing nearby while "on call".  But I'm not sure the trade-off of friends, family, and urban conveniences is worth it.  I looked forward to work everyday, but I couldn't figure out whether it was 'cause I enjoyed suturing legs up at 2am or because the alternative of watching the clock tick until my next shift nearly made me slash my wrists. There were days where I'd get off work, hike, come home and it was still only 6pm.  From there, it was TV and youtube.  Not a soul in the street to chat with.

Verdict?  Rural medicine is great.  It takes a certain maturity for a city boy to trade off friends, family, and glitzy social scene of urban life though.  I'm certainly not there yet.  If I pursue family medicine in the future, I hope said maturity will be there.  After all, rural medicine is definitely the way to do family medicine.

Pre-Clerkship Advice Series: Academics

"Be careful whose advice you buy, but, be patient with those who supply it.
Advice is a form of nostalgia; dispensing it is a way of fishing the past from the disposal, wiping it off, painting over the ugly parts, and recycling it for more than it's worth."

8000.  That's my estimate of the number of hours I've spent in the last 2 years devoted to medicine.  Along the way, I've learned a trick or two that I wish I'd known back in September of year 1.  So for all the incoming medical students, I humbly present to you my first blog series:

Red Frisbee's Guide to Surviving BEING AWESOME! in Pre-Clerkship:

ACADEMICS
Medical school is a full-time job (sometimes it feels more like 2). 

A lot of my peers started medical school fresh from an undergrad degree.  In fact, one of the girls I'd pseudo-dated, like many of the other young'uns in my class, hadn't even finished her bachelor degree yet (she was legal...I'm pretty sure).  I, on the other hand, had spent my a couple of years prior to med school being the opposite of studious - being a hobo, working for "the man", and living a nomadic backpacker life. 

Although those years away from school effortlessly stripped away many of the tactics I'd learn in my undergrad years, I'm not sure I was necessarily at a "study skills" disadvantage.  Med school, after all, proved to be a different ballgame for everyone.  There were so many times where it felt like I was trying to drink from a firehose. 

After serving my first 2 years in medical jail school, studying effectively has become easier.  My best suggestion is do what works for you, but here are my study tips to doing well and getting through to the next semester.

1. Hit the ground running
It's still surprising that I managed to survive 1st year considering I crammed like nobody's business.  I did fine on the exams, but retained far less that I should have.

In 2nd year, everyone that I have talked to said year 2 was far more difficult (likely dependent on which school you're at).  I did far better and found it much more manageable because I actually kept on top of things right from the start line.  Still, I've had countless moments of "why don't I even remotely remember this topic?" everytime I looked back at what was taught a month ago.  Unless you're blessed with one of those "hear it once, know if forever" memories like some of the folks in my class, give yourself plenty of time to learn it several times through the block/semester.  Cramming in med school and keeping your sanity are mutually exclusive.  Start reviewing right from week 1.

2. At the end of the day, if you try to know it all, you will kill yourself
Nobody can know it all.  You won't.  The keener at the front won't.  Your doctor won't. 

There have been few exams where I don't recall people at the "high end of the spectrum" in my class feeling like they are going to fail an exam.  Yes, you absolutely need to know the details but it's pointless to stress over not knowing all of them. 

I learned to keep calm by appreciating that the feeling of "not doing great" is inevitable.   Never forget that at the end of the day, your chances of failing (even if you absolutely believe it) are very low.  And even if you do, it's not the end of the world (no one in my class has "failed" out of med school - they get kicked out for far dumber reasons like being cracked out while on duty).



3. Learning Resources
Accept that you will have to build a library
Here's a moment of extreme nerdiness.  I discovered this year that I have a huge crush on books (or if you prefer a "book boner").  I think I purchased 4 or 5 textbooks max in my undergrad years.  Unfortunately, medicine has SO much crap that you absolutely cannot get away without having an effective collection of resources.  Your classroom powerpoints will not cover everything you need to know.  Google and wikipedia will not cut it.  Neither will MD Consult/Access Medicine.  Nor Uptodate.com (these are all great resource by the way). 

Be selective when you do
My personal library is still scant compared to my friends' collections, but that's because I'm selective.  It's easy to become over-resourced once you hear Joe Blow describe how good a book is, or how Susie McSmartass gleams over her new set of antibiotic flashcards.  Over-resourced = overwhelmed = not effective studying.  Take a good look at what you think IS useful and buy those, especially if you can use it throughout the years.  I suggest just start with a good anatomy book and atlas, Toronto's Notes (so concise!), and a clinical skills book (Bates!).  If you have those 4 essential things, you've got a solid foundation and you can add to those PRN.

Pick books that are clear-cut (usually you can get recommendations from friends).  And get PDF's of those that you won't use much.  An Uptodate.com subscription is great but is more useful for the clerkship years.


4. Class
To go or not to go - that is the question
"Wow, I gained absolutely nothing by coming to class today.  I'll still have to go home and spend another 2 hours going through each lecture I sat through."  That's the thought I had in 90% of my days in year 1.  By year two, I smartened up and quit going to class.  That doesn't mean I was sleeping in or out playin' hookey Ok, I went snowboarding more than I should have.  But, nearly every class I wasn't in, I was in the library or at my desk learning the material being taught to my sucker classmates at that very moment .

I was able to go through new material, make my own notes, and most importantly - understand it!  Lecturers zoom through lectures super fast and my feeble brain ain't capable of keeping up.  I ended up saving a lot of time by skipping lectures and knew the material far better by the end of each week.  If you have a small group (see point 5) to chat about the material with, that's even better.  Provided you haven't tried to sabotage your classmates, they'll let you know when is something important mentioned in class you missed (which is about 0.1% of the time).


5. Study group
"I'd love to play poker tonight guys, but I'm meeting with my study buddies tonight." *Snorts and pushes nerd glasses up*
Maybe a study group was your saving grace during undergrad.  Maybe you were the Abercrombie douchebag who laughed at the thought of it.  I was never a firm believer of these until med school, but they definitely saved my ass more than once.  Set a designated time and day of each week to go through what was covered during the week.  Once routine kicks in, they aren't a drag.  It's amazing how different 4 or 5 brains can come up with far more perverted mnemonics than just 1.  And it's comforting knowing that others are going through the exact same excruciating pain as you.  Throw in a beer at the end of the session and life is suddenly a whole lot sweeter.

I also found that going through our Clinical Skills weekly made me a superstar in the clinics as well.  I never took clinical skills seriously during my first year but lemme tell ya - OSCEs are a bitch if you don't practice regularly.  I'm writing this while I'm on a Family Practice rotation right now and my preceptors have been very happy with my patient examinations.  And, again, a glass of wine during clin skills practice sessions are nice too.



6. Get Your Money's Worth!
A lot of my peers were hesitant to get help from the profs and doctors.  I never understood this.  They are being paid by the public and my 20K tuition a year to do their job...teach!  Email them nicely with your questions and they are generally super friendly and willing to help you out.  If you're hesitant just remember...you paid for it - milk it for all it's worth!


7. Lather, Rinse, Repeat
Go through things again.  Then again.  Then again.  Most of clinical practice is common sense, but a lot of the science behind it is not.  Do whatever practice questions you can to help yourself.  Then go through things....again.

Good luck everyone.  Remember - the idiot that everyone knows about in the year above you made it through.  You will too.

1750km drive from home

It's June 2011. 2 years of classroom work later, I'm halfway through my MD. After roughly 750 lectures later, I can safely say I'm (for the most part) done being hosed down by powerpoint lectures. But that's not what I'm writing about today.

Every year, my school marks this occasion by sending its seasoned textbook-memorizing, hospital-drama virgin students out to the bush into rural communities. Each of us spends a month working with docs in communities ranging from smaller cities to those with populations in the hundreds. Students either jump at this opportunity or cringe at the thought of being isolated away from their nearest Starbucks franchise.

Fortunately for myself, I am stoked to be working in a community of only 400. Docs here do everything from stabilizing their neighbour's bbq burns to running clinics in helicopters. I have no doubt that this will (A) negate all the bad habits I picked up in Vegas post-exams (thanks, boys) and (B) revitalize medicine for this young buck. It's been a year since I worked in rural India and another dose of romanticized medicine couldn't come at a better time.

The drive took 2 days, but I'm in the most northern part of my province just chilling with the grizzlies in bear country. The air is crisp. The sun set was midnight last night. The people smile. Aside from the exorbitantly marked prices of food here, I have absolutely no complaints. What other degree sends you out to explore your nation, soak up the culture, fly-fish/hike/hunt while learning about your trade as well?

Armed with my Canon 7D and bear spray, I say "bring it"!

I felt cancer for the first time

I enter the examining room and see 2 women sitting waiting (elderly and mid-late 30's). Assumption is the daughter brought her mom in for the appointment. I do a quick glance at the charts, listen in to the doctor chat and quickly realize the silver-haired elderly woman brought her daughter for her regular weekly checkup for palliative care. Mom is carrying a clipboard that carefully documents the medication schedule and her daughter's daily treatment routine. Her frail daughter, first diagnosed at 29, has chondrosarcoma. The tumor is cartilage and has grown throughout her entire abdomen. Barely even able to walk comfortably, the daughter says to me with a genuine smile, "Yes, of course you can feel my stomach. It'll help with your learning."


I'd learned about it in my classes - the investigations, staging, treatment, services available etc. for cancer. It took nearly 2 year, however for me to actually feel it. I felt it in my hands as I palpated her stomach. I felt it in the room as we chatted.

The experience definitely left an impression on me. Sure, it tugged on my heart strings, but I'm not talking about the "must hide!!! man tears about to roll out" kind of impression. It hit me how easily a perfectly normal person can suddenly fall rock bottom because of something completely out of her control. This young woman was diagnosed at an age just a few years from where I'm bound, and the dead-end to her path is more or less already determined. Now I'm even more irritated by fat-asses that sit on their couch and don't exercise - at least diabetes and heart disease is preventable. But that's a rant for another time.

My patient also reminded me of how often I will be seeing this in the near future. This was my first "oh crap, this woman is going to die...soon" situation. It was no doubt a Mickey Mouse experience compared to what the few years will throw in my face, but you always remember your first time with everything, right?

Canadian Medical School Interview Questions

Big mean interviews. I'd always wanted to do a cross Canada trip. In 2009, in a way I did - only it involved many planes and me flying back and forth the nation every weekend for about a month - and even once while I was backpacking through Honduras (btw thanks, Toronto, for the short notice!).

In a few months, thousands of eager-eyed pre-meds will have been grilled by all sorts of medical "professionals" about their medical ambitions. Doesn't seem like it was so long ago that I was there myself. I still remember sitting in my living room with my wonderful roommate at the time practicing for medical school interviews.

I, of course, remember desperately googling tips and hints for schools. Wasn't easy, so here's my contribution back to the world of the pre-meds. Credentials? I did interviews at 4 Canadian schools (and even Australia as a backup) and was accepted into all but one school. So here goes:

Disclaimer: it's been several years and selection processes have surely been updated along the way.

University of Toronto:
Interview style: Panel (one 2nd year medical student, one doctor/health professional)

Unlike any of the other school I'd interviewed at, Toronto really knew my portfolio. They paired me a doctor who worked in my area of interest at the time (non-profit community health medicine). Their questions were fairly straight forward. Know your history well, strengths & weaknesses, learning experiences etc.


Other Schools: Here's a list of questions modeled after those that I actually had. No questions are actually from interviews, but they are very reflective of the ones I was asked.  Feel free to comment on how you'd answer.  I'll try to give some feedback.   

MMI Questions (good for University of Calgary, British Columbia, an Manitoba):

1. You and your best friend try out for the varsity track team. You just find out you got in, but your friend was rejected for the 3^rd time. Enter the room.

2. It has been argued that wait times for organ transplants can be significantly sped up through surgeries and donations from other countries. You are a physician working with a patient who you noticed had recently gone to the Mexico to receive a liver transplant. What are the ethical issues involved?

3. You are a third year medical student involved in the research of Dr. A, a senior physician. He is testing the efficacy of a new drug on lowering cholesterol. This drug is not yet known be more effective that existing drugs on the market. He insists that you recruit patients for trials even though the clinical risks of the research are still undefined. What are the issues involved for the patients? For yourself?

4. What is the biggest accomplishment of your life? What is the biggest disappointment?

5. As medicine advances with technology, what are the pros and cons? Discuss your experience with use of technology.

6. Dr. Who is a physician for Mr. Bean and his wife. Dr. Who discovers that Mr. Bean has an STI. Mr. Bean does not wish to tell his wife . What should Dr. Who do? Explore the ethics surrounding this scenario.

7. You are a resident working in a team of several others for on call shifts. You and your partner just had a new baby. Would you re-adjust the call schedule? How? What problems do you foresee and how would you approach the problems?

8. You are a young, single doctor working in a small town of 1500. You meet an attractive male/female at the bar that you are interested in. What problems do you foresee?

9. You are a GP working in a community where the majority of patients have very little education and many are refugees from other nations. What challenges do you foresee?

10. Describe your experiences with physicians. What traits would you and/or would you not emulate?

11. Data has shown that doctors who smoke are less likely to make good role models for patients. Should doctors be allowed to smoke? Do doctors need to be role models?

12. You are a first year medical student who is doing above average in some subjects, and below average on others. What would you do in this situation? What resources would you access?

13. You are working in a clinic for street youth. A 16 year old girl comes in seeking sleeping pills that you do not think is appropriate for her. She says she will see another doctor if you do not prescribe them. What would you do?

14. You are a physician who has finished his or her day and decide it's appropriate to leave on time for the first time in months. You have promised to meet your family for dinner. You suddenly receive a phone call from Mrs. Black, a 87 year old patient in a nursing home long time, who wishes that you attend to her long-standing condition. She has been patient of yours for 15 years and refuses to see another doctor. What issues are involved? How would you approach this situation?

General MMI tips:
- Come up with personal experiences that you can apply to each of these situations. This allows you to personalize your answers. You don't a long list since each MMI station will have a new interviewer and you can always repeat experiences in your answers.
- Smile! A classmate of mine was recognized by a faculty member after she got it: "you're that girl that smiled a lot!"
- Sum up what you said at the end if you have time.
- DON'T RAMBLE! Silence is ok.

"coconut blood transfusion! It actually worked!"

It's been advertised like crazy. Off the Map (OTM), from the overly imaginative producers of Grey's Anatomy, fires onto cable television tonight. I'm not a follower of medical dramas whatsoever, but there was something that made me excited about this one. I've been a long time avid traveler (one continent left!) and have been been spearheading my faculty's global health department as well as gaining hands-on field experience myself. I guess it was this travel medicine bit that made me set the premiere on my iPhone calendar.

Well - my review is premature since I'm watching it as I type this (multitasking!). But let's look at the salient features of the show as well as some of the best lines I've heard on it.

Synopsis:
Young, good looking docs travel thousands of miles to re-discover why they entered medicine. Each has a different personal story, but they are bonded by their common need to run away from their life in the states. Within the first days of working, they are learn deep life lessons from the local seasoned doc and encounter riveting moments as the locals express profound gratitude for the American's altruism.

Hmmmmm...I can't even comment on this right now. I need to get a sweater to cover up my goosebumps.

Best lines:

"coconut blood transfusion! It actually worked!"
WTF?! Coconut transfusion? I can't wait to bring this up in the wards when I'm in the hospital during to an ER surgeon if we are ever low on the human donations. Just think how impressed he'll be. Sign me up for Gilligan's Island!

"I'm not a surgeon" - blond female doc
"Here, you're a surgeon........you're anything I need you to be." - the surgeon dude
I'm mentoring several groups going abroad this summer and if they pulled that on me, I'd sit them by the cow patties for a serious time out. Doctors who work outside of their skill set completely violate both basic global health ethics and medical ethics. You can't pretend to hone skills that you don't have just because you patients stem from lower resourced community. Can you imagine if a family doctor performed a triple bypass surgery on you? Yes - they WILL kill you.

"My grandma is 80 years old, but today because of you, she took her first real breath." *Tear*
Grandma reaches into bag and presents the sexy blond doc with a thank you chicken. *Insert chicken sounds*
This was actually probably the most realistic part of the show (minus the teary eyed patient). I remember a friend being presented a goat once when he was in Uganda. Back it went to the community.


Verdict?
To the 10th graders vying to be doctors, please take nothing away from this aside from the fact that doctors are obviously all gorgeous people. Apparently we are also all white (you can also be black, but only if you play a minor role in the show).

But let's take a serious look at global health and the show. My university has become a leader in filling in health gaps of lower-resourced communities. In fact, I just came back from workshop on it and am meeting the Dean of Medicine tomorrow about the future of it in our faculty.

I've been fortunate enough to learn first hand about the pillars that support the field: the ethics in working with developing nations, project development, acute disaster relief, cultural competency, needs assessment etc. OTM, like many other sugar-coated medical shows, glamorizes what medicine actually is. While doing so, it also completely distorts what it means to go abroad to practice medicine. Basic medical morals are thrown out the window and anything goes.

The show does have its merits though. For one, it fuels my fantasy that one day, medicine will actually be like that - I can save people with coconuts, fight my inner battles by saving a South American granny, and, along the way, hook up with a ton of hot young doctors who are also soul-searching.

Conclusions about OTM? I will probably stop watching the show here. It makes me angry that global health is presented in such a childish manner. But I will sleep soundly at night knowing that the public now has another reason to believe that docs working abroad are the modern sexy version of Mother Teresa.

New Years Resolution!

This morning I laid in bed thinking how much I wanted to re-unite with that thing. What's it called? Oh right, "life". And when I do, it'll probably be awkward since it's been so long since we've hung out. This semester is going to be different though. I am going to make our relationship work!

The last quarter of my classroom training in pre-clerkship (i.e. before hospital wards) begins tomorrow. The routine begins again - start of semester and RF is happy-go-lucky. Things are looking rosy for him. He enters the boxing ring to fight off the contenders. Standing at the other corner - early mornings, late nights, condescending teachers, arrogant peers, super keeners, ladadadada. All good until BAM! K.O. as exams enter. Before the unavoidable K.O. though, I'm going to make this relationship with life work out. I refuse to let medicine consume my life.

"So, RF, what are you going to do?" you ask. This is where resolution edition 2011 comes in: I'm going to go out of my way to pick up "destressing hobbies" and avoid burnout (aside: according to several tests, I am at "very severe risk or burnout"). And along the way, I'm going to blog about it to make sure I stick to them. It'll be kinda like a fat camp diary - except instead of shedding the chunk, I'm shedding the stress. Feel free to throw random suggestions for stress reduction my way! I'll definitely try them if they don't involve harming little puppies.