Friday, May 11, 2018

The Death and Life of Canadian Medicine, Part IV

What happens in med school doesn't stay in med school.

Previously: Part I, Part II, Part III

It's almost a miracle that Canada's medical system works as well as it does, with doctors as skilled and as dedicated as we have. Simply put, the modern medical education system takes the brightest young Canadians - whether they have the right attributes for medicine or not - and buries their best attributes under the cynicism of the med school admissions and residency application processes.

The selection process for medicine doesn't actually begin in university, but rather grade 11. Some would-be doctors will have the idea ingrained even earlier in childhood, if a relative or family friend is a doctor. But grade 11 is the point at which brighter high school students opt in or out of advanced math and science courses, the prerequisites for studying science at university. First year university passes much the same for the student as late high school did, with a mix of classical science and math courses.

In second year, the undergraduate encounters the dreaded Organic Chemistry course that will make or break his or her chance at medicine. Organic Chemistry probably culls one half to two-thirds of students thinking of a career in medicine, no small achievement for a subject that brings little to bear on clinical practice. If the student passes the Organic Chem stumbling block, he or she goes on to finish a Bachelor's (and increasingly, a Master's or professional degree) and begins the work of building a med school resume.

In addition to having extremely high grades, prospective med students are expected to have amassed experiences that look good on the application - time in a lab, volunteering in different settings, achievement in the arts, and so on. Then comes the MCAT exam and the not-inexpensive school application fees ($220, plus $100-150 per school). The odds of success throughout the process can naturally be improved upon, thanks to a massive industry (formal and informal) comprising: message boards; Facebook pages; Twitter feeds; MCAT prep courses and review books; application reviewers/editors; and mock interview services.

If successfully admitted to medical school, the student (or the student and his or her family) faces upwards of $100,000 in tuition and cost-of-living expenses over a three-to-four year MD program. The curriculum and teaching methods are constantly evolving, but almost all of med school is taught by specialists and sub-specialists, whose positions and promotions depend largely on research output. Accordingly, interest in research is a prized character trait in med students.

Medical school is, of course, incredibly demanding and time-intensive. Some med students will manage to work part-time in their first year, but it's no longer possible once clinical and elective rotations begin. Once he or she enters proper clinical training, the student begins a mad dash to find a specialty of interest, buff up a residency application with some sort of extra-curricular work (usually research), and arrange electives in all the right places with all the right supervisors. That is, unless the student has designs on Family Medicine or a lab discipline (Pathology and the like), in which case he or she can focus on learning the art of medicine without fear of anything but the disappointment of specialist supervisors and specialty-bound peers. And we wonder why so few med students take an interest in Family Medicine, outside of the nature of the work itself and the pay. But I digress.

A couple of things are worth noting about this entire system as it is now:

Med students are disproportionately (and one hopes, unintentionally) chosen on the basis of math skills. Inorganic Chemistry and Physics are, for all intents and purposes, mathematics courses, using mathematical formulas and calculations for most, if not all, of the coursework. So what's the most likely explanation for Organic Chemistry weeding out would-be doctors the way it does? Organic Chemistry introduces visual-spatial concepts that aren't found in other scientific disciplines, and understanding those concepts requires different cognitive skills. So what of the other (and arguably, more important) cognitive skills needed for success in medicine, like critical thinking, interpersonal communication, and self-awareness? Yes they're taught in med school, but what about selecting for these skills and character traits long before? If a Social Work student couldn't get higher than a B in Calculus, who's to say he or she couldn't have been a spectacular doctor?

Admission into med school is almost divorced from the practice of Medicine, and is biased towards the affluent. A student can't volunteer at a hospital or a lab if she has to work to pay the bills. A student can't work in the developing world without parents to pay for flights, or learn to play a sport or instrument without parents to pay for lessons. The MCAT takes an inordinate amount of time to study properly for. And it's wasted time and money, considering that it adds no value to one's medical education, and the preparation courses that increase the odds of success are expensive. As for the rest of the "get into med school" industry? Expensive, cynical, and of dubious value to a society in need of doctors willing to work in, and for, disadvantaged communities.

Med school is dominated by the residency application game. An older surgical colleague told me not long ago (with tongue in cheek) how interesting it is that so many pre-med and first-year med students "feel destined" to enter Radiology or Ophthalmology. To which I would add that rarely does one hear the same sentiment expressed about Psychiatry or Family Medicine or Pathology. Obviously money and prestige once out in practice are the primary motivators here. But the effect is that for many med students, jockeying for a prized residency spot becomes more important than learning the art of medicine. That means med school isn't med school anymore, but rather yet another contest. Forget what the expense and stress of the residency match does to students - up to and including extreme mental illness - how is the paying public served by all this?

By and large, though, Canadian students still graduate med school full of pride and enthusiasm. Once the residency match is over (for all but the unfortunate ones that go unmatched), students are ready to give it their all in service of the medical arts. Then comes life as a resident, where cynicism too often gives way to despair.

Next: the self-defeating crucible of residency


  1. Love reading your articles. I am not a physician, though I am married to one.

    I would say the MCAT works well to reduce the number of applicants to a manageable point. Entrance exams are also the standard now for MBA's and Lawyers. It's also a way to separate the truly serious from the passing-fancy applicants.

    I heard all about the residency dance being done during medical school. What I know is that it becomes a popularity contest wherein prospective residents try desperately to be liked by the head of their desired specialty department.

    I might also put out there that the elephant in the medical office is the growing gap in pay both among different specialties and with general family medicine.

    1. Thanks so much for the comment!

      At least one med school - McMaster - did away with the MCAT as a prerequisite for application (although I don't know if it was brought back). There is no evidence that the quality of doctors McMaster graduates is any less than other Canadian schools (perhaps myself excluded). I can see a rationale for its persistence in the U.S., where there's a monstrous gap in resources between lesser Colleges and the elite schools offering undergraduate education, but not in Canada. And given the costs and strain of applying to med school these days, and the almost superhuman expectations placed on candidates, the notion that anybody would apply to medicine as a passing fancy doesn't really hold water.

      The pay discrepancy problem - what we in the biz call relativity - is less of a problem in career choice between family medicine and specialties than it is between the choice of one specialty over another. And I'm now of the mind that it will never be solved, or a "solution" will simply be foisted on the profession by the government. Medical associations are simply too tribal and weak by design to agree on it. And every time some panel or committee convenes to derive a formula to address relativity, it's the same 4 or 5 specialties at the root of the apparent problem.