Should you go to Med School? Probably not.

Medicine has long enjoyed its reputation as a distinguished and well-respected profession with an assortment of perks. Not just in Jamaica but worldwide, doctors rank up there with lawyers and politicians in the hierarchy of  ‘jobs you want your kids to have’. Children with even a mediocre aptitude for science get pushed into medicine and often for the wrong reasons. If you want to be a doctor because you “like helping people” or just so you can put that “Dr” in front of your name you probably shouldn’t go to medical school.

If you like helping people that’s awesome, but you have to be realistic about what exactly you’re working toward and what that work involves. (If you just want the fancy title, get out now). I’m not trying to discourage anyone from becoming a doctor but I do think it needs to be said that being a doctor isn’t for everyone. Similarly, being a garbage collector or plumber isn’t for everyone. And yet someone has to do it. You can appreciate this comparison once you understand that the way we ascribe meaning to jobs is totally arbitrary and ultimately pointless.

People who create immense joy and inspiration like musicians or writers are not revered or compensated equivalent to the value of the work they produce. Conversely our government leaders who exist to serve the tax-payers who elected them are revered and compensated entirely out of proportion to the work they don’t produce.

The bottom line is this: If you could be guaranteed the same amount of wealth and respect by working as a grass cutter (or any other underpaid job), would you still want to be a doctor?

If you said yes, be prepared for a lifetime of hard fucking work. Getting accepted to medical school is only the first hurdle, and it’s a pretty big one. You need the right grades and a decent collection of co-curricular activities. In today’s society it helps if you know the right people. The sheer number of applicants to medical schools annually is staggering; competition is fierce and it will be like this for most of your career.

Aside: If you don’t get into medical school it isn’t the end of the world. If after reading this article and doing your research you decide that you 110% want to do medicine there are ways and means. And you’re young, you have so much time. If after the soul-searching and the research you decide it isn’t for you then congratulations! Go do something that makes your heart sing.

Let’s say you get accepted to medical school here at the University of the West Indies. If your parents can’t afford to, you now have to figure out how to finance all five years of your education. A part-time job is out of the question because you won’t have the time, scholarships are hard to come by and student loans are expensive to repay. Where do you turn then?

Let’s say you decide to take out a student loan. Now you have to hit the ground running with your studies. Medical school is essentially a brain dump of information, most of which has to be memorized until you can understand it enough to apply it. There is constant competition among your peers in tutorials and exams and a stifling atmosphere of one-upmanship. The pressure to continuously outperform your colleagues rarely lets up. Starting here and continuing for a good half of your career, sleep will become a hypothetical concept.

Once you graduate, you’re staring down the barrel of what will probably be the worst year of your life. Internship is a grueling marathon of stamina and skill with the added weight of being responsible for people’s lives. And halfway through the year, if you took out loans, the Student Loan Bureau will come knocking.

If you decide to pursue postgraduate studies, you’re looking at another 3-5 years of school, loans and now trying to balance your family life (probably) with your career and education. If you don’t pursue postgraduate studies, your marketability plummets and your pay grade stagnates. Either way you will probably go prematurely gray from the stress of it all.

If you’re still not re-considering, you’re likely thinking one of the following thoughts:

But doctors are rich!

Unless they inherited wealth (which admittedly, a good many doctors do) doctors aren’t rich. For an average Joe from a lower to middle income family, it takes several hours of overtime to maintain the lifestyle the public usually associates with doctors, especially in the early years of a career. In the grand scheme of income rates, Jamaican doctors get paid very poorly compared to our international counterparts (even South African doctors get more money than we do). But there a lot of different factors influencing how much money you make, most importantly post-graduate study.

But doctors are well-liked/respected!

This is true to some extent. Certainly doctors have special privileges: people smile at you more (people smile at puppies a lot too), you can stand as a character reference (so can ministers of religion) and banks tend to want to lend you money (it’s a trap, Jim). But like Uncle Ben said, with great power comes great responsibility. And if you slip up even once it’s a long way down.

But doctors are _______!

It doesn’t make sense to generalize. The experience of the doctors you have so far been in contact with will not be your experience. The field of medicine is constantly changing and rapidly evolving. It isn’t now what it was fifty or even ten years ago. Technology makes things easier and harder, popularity and accessibility make competition a hundred times fiercer, and regulatory bodies have turned medicine into a business, always looking at the bottom line.

The volatile landscape of the medical profession demands a special kind of adventurous spirit who does their research beforehand. Map your territory. Talk to a medical student, talk to a young doctor, talk to an older doctor, shadow them at work, flip through a medical journal, visit a hospital. Get a feel for the shoes you’ll be walking in.

And after you’ve done all that, talk to yourself. If you have a keen interest in helping people, if you love challenges and relish hard work (and care very little for sleep), if you’re naturally competitive and have a good head for business with a passable understanding of the human body then medicine might be the career for you. Otherwise, set your sights elsewhere. Preferably something in line with your natural inclinations.

Might I suggest Banking and Finance?

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Doctors and Mental Health

The lives of medical professionals (at least the part of our lives that we choose to share with the public) are a lot like Instagram posts: lots of happy, successful moments to build the image of being competent and caring. But just like Instagram, real life is never as perfect as that carefully curated snapshot.

If you remember my last post about the things we don’t talk about, there was one really important topic I left off that list:  mental health. Just like physical health, our psychological well-being is integral to the way we function. But while we won’t hesitate to get ourselves checked at the first sign of illness, we balk at the idea of talking about our feelings or worse, spending time in therapy.

Sometimes we don’t talk about it because we feel our patients need to believe that their doctor is operating at peak performance. Discussing our mental health issues openly, or even acknowledging them can have a detrimental impact on the physician-patient relationship. Patients tend to think of doctors as superhuman, somehow immune to the struggles that plague the average person. In reality, doctors have the same problems as everyone else. But we don’t like to be reminded of that. We buy into the con, believing that we are somehow capable of feats no one else can do.

Sometimes that’s allowed, even expected – not everyone can perform brain surgery or resuscitate newborn babies – but other times we overreach. Doctors frequently pull stunts like trying to function normally after 36-48 hours with no sleep. We sweep treatable issues like depression under the rug because of course we can handle it, self-medicating with substance use or else ignoring the problem entirely until it can no longer be contained.

The medical profession carries one of the highest rates of suicide (1.4-2.3 times the rate of the general population). But discussing an issue that can call into question your fitness to practice is absolutely off-limits. In the most ideal and ethical situation, doctors would put the patient’s interest ahead of their own security, but we are human first, driven by the same fears and needs as everyone else. And there is a very real fear that any perceived disability will end or permanently blight our careers.

On top of this is the associated stigma of mental illness that is so very rampant in Jamaica and the Caribbean. No patient wants to see the “mad” doctor who “tried to kill himself”. But if any progress is to be made in erasing this stigma we physicians have to be the pioneers. And since this stigma persists even among doctors, we are the first hurdle we have to clear. After that, education and sensitization of the wider society.

Even though no one seems ready to talk about it* (Megz over at Barefoot Medz is one of the few, doing a really great job) mental health is a discussion we need to have. In such an emotionally draining and psychologically demanding profession it isn’t fair to anyone to have doctors fumbling to look after their mental health alone.

We need to catch mental health issues among physicians from early, as early as medical school even. Mandatory psychological screening for depression, anxiety and PTSD among others should be instituted for all the high risk professions: doctors, police officers, firefighters. We shouldn’t have to wait until a doctor commits suicide or a policeman kills his spouse before doing something. Prevention or at least early detection is paramount.

There’s a lot of work to be done. Efforts have started but they’re halfhearted at best and the government offers little in the way of support. We must be our own advocates and work with other key players to remind the public that there is no good health without good mental health.

*

Further reading: a pediatrician’s experience with psychosis, and a GP’s experience with depression.

*After writing this post, I discovered Dr. Eric Levi an ENT surgeon who is also making strides in the discussion on mental health in doctors. 

Big Pharma in Little Jamrock

a Third World Perspective on the Ethical Dilemma of Drug Company Gifts

Who doesn’t love presents? Santa Clause, your mom, your boy/girlfriend – doesn’t matter who it’s coming from, as along as the tag has your name on it (and you don’t have to pay). Can you imagine if you could get presents, not only from people who care about you, but from people you associate with in the professional sphere?

What, presents from work colleagues? Not quite. Gifts and privileges from medical representatives trying to push their products. What’s the harm, you might ask. I’ll take their stuff, but my prescriptions don’t have to change. Besides, so what if I prescribe Brand X instead of Brand Y. The patient still gets the same drug.

But there’s plenty of harm.

Multi-million dollar pharmaceutical companies, affectionately called Big Pharma, spend tidy sums of money each year keeping physicians loyal to their brands. This comes across as fancy dinners, paid vacations, or even just catered meetings. The medical representative proffers the olive branch of food (usually) in return for the chance to remind physicians why we need to prescribe their pills.

This, of course, can have disastrous repercussions for patient care, particularly when the ethical practices of physicians are called into question. For this reason the relationship between doctors and drug companies is heavily regulated in the United States and other countries. But in Jamaica physicians are left up to their own devices when handling drug company influences.

For the most part the attitude of Jamaican doctors appears to be politely non-partisan. We’re appreciative of the benefits meted out by medical representatives, but brand loyalty isn’t a widely supported concept*.

In medical school our lecturers went to great lengths to teach generic names instead of brands for common drugs. It’s a habit that sticks until you start working with doctors who almost exclusively use trade/brand names and then all our lecturers’ hard work is undone. And strictly prescribing generics becomes impractical when you start to consider affordability, brand vs. generic efficacy (and there is a difference) and of course patient preference. Most of our choices as doctors will be based on one or more of these factors, not just which company gave us better stuff.

Another aspect of third world presents that differs from our first world counterparts is the quality and scale of the benefits. I hear stories (from the U.S.) of travel expenses being covered and expensive electronics being gifted to conference attendees. Big Pharma has even literally paid doctors cash to recommend their products.

Now I am a still a small fry in this medical business, but I just don’t see Lil Pharma here in the Caribbean shelling out that kind of money. We get catered lunch meetings and one or two free conferences for medical education purposes, but the average ‘kickback‘ here is most often a pen or some hand sanitizer. Really, it’s like they’re not even trying (by comparison).

But this doesn’t necessarily mean we aren’t being swayed. Especially when you add in other local factors like how Jamaica is so small that chances are you’re actually friends with one or two medical representatives (and so feel compelled to prescribe their drugs). Or how Jamaica has so much corruption that even if physicians practiced unethical brand loyalty people would probably still turn a blind eye. On the other hand, Jamaica is so poor that most patients aren’t able to afford fancy brands anyway so it’s not much use pushing those medications on our market.

This is where public and private practice diverge widely. Patients in the public system are treated based on availability of medication because for the most part they cannot afford to pay full price for their medications. Pharmaceutical companies sometimes bid for spots on the National Health Fund subsidy so that their drug can reach a wider base. Yay, right? Not necessarily. These are the cheaper drugs, often generic formulations and usually older than what the rest of the world is using. Standard of care takes a back seat to any kind of care we can manage at this point.

By contrast in private practice, patients are generally seen as wealthier and more actively involved in their health. These patients usually don’t mind paying more for a brand name medicine if they feel it works better than the generic, and this is where the industry can get a toe in the door. This is where the ethical dilemma of industry gifts begins to take root. And if we are going to start any kind of regulatory or even supervisory process this is where we must investigate first.

But for now people are comfortable. Patients get their medications, physicians get their food, and Big Pharma gets their profits. It’s a win-win-win, until someone (likely the patient) loses.


*Not statistical. Based on my own (limited) observations.

Conquering Duty Anxiety

I really don’t like being on call at the hospital.

Yes, someone has to do it. Yes, we get paid overtime to do it. Yes, this is how we gain experience as doctors. But all of those logical structured reasons fade away when I’m startled awake at 1am by a nurse calling about the patient in cubicle 5 who won’t stop bleeding.

When I was on pediatric medicine I would have a lot of anxiety to deal with on duty. It’s terrifying to be the first responder to a critical situation when you’re not 100% sure you can handle the case. To make matters worse, I was dealing with babies. Delicate (yet somehow also borderline indestructible) little human beings. In the beginning I would have regular panic attacks and palpitations, but as time went on I got more comfortable handling the common emergencies. I became more confident in my abilities, and could usually rest assured that if there was anything I really couldn’t handle, I could call my senior.

The most pervasive part of duty anxiety for me, though, the one that crops up on every rotation regardless of my self-confidence is the uncertainty about being called. You can never tell whether a night will be calm or hectic, whether you will be called ten times in one hour or once for the whole night. And that kind of unpredictability is anathema to me.

As humans we like to think that we have control over our universe. As interns we have all kinds of superstitions for keeping emergency duties light. Knock on wood to keep the bad karma away; when you notice that a night is being particularly uneventful, you can’t say so out loud or you’ll jinx it.  We do these things to try and hold on to the idea that we can dictate how a night will progress just by monitoring our actions.

But letting go of duty anxiety means letting go of the crazy notion that what we do or think will somehow impact the chances of a patient taking a turn for the worse. Or will somehow keep a hundred people from turning up in the emergency department in the middle of night.

It won’t.

The night will unfold as it was always going to unfold, whether or not you stay up having the world’s most intense staring match with your phone, whether or not you knock on all the wood. Whether or not you try to grab a few hours of sleep or comment on how quiet the wards are being. All the superstitions are doing is tricking you into thinking you have some measure of control, so that you think it’s your fault when the emergency duty turns into a madhouse. “I have 3 emergency surgeries because I didn’t knock on wood this morning”.  It sounds completely illogical, because it is. But that’s usually the nature of anxiety.

I have found that the best way to conquer my duty anxiety is to relinquish this idea of control. To let the night progress as it will, without trying to force it into whatever hopes or expectations I might be harboring. When I do that, when I go about my tasks and breaktimes free from the thought that what I’m doing will make or break the night, I find that I’m a lot less anxious and a lot less tired too.

Dear UWI: Please Wear Your Size

Once upon a time medical school class sizes numbered about 40 people. The student : consultant and student : patient ratios were low. Everyone had an equal opportunity to see and touch and hear things. Future doctors had to know all the things, had to write essays, had only a handful of textbooks and a ward full of patients. All was right in the world.

The good old days.

Then came the surge in tertiary education accessibility and this strange idea that everyone who was bright had to do science i.e. medicine. What followed was a welcome blossoming of the medical field. Now we had extra doctors to fill in the gaps previously patched up by family nurse practitioners and old doctors long past retirement. All was even better with the world.

But the numbers kept climbing. What started as a welcome trickle soon became an unstoppable torrent and the volume of graduates was starting to spill over the buckets we had to catch them. It’s been going on for a while, but in the last three years it’s been getting a lot more noticeable.

It’s not just the numbers that are the problem, either. Historically, UWI doctors have a reputation for being unparalleled clinicians because of the overwhelming amount of exposure we’re supposed to get on the wards. Our consultants tell us stories about being in final year and getting a stipend for acting as interns. They’re full of back in the day type stories but to us they’re just that: stories.

Our reality is lecturers who are a hundred miles away, histology specimens on LCD screens and anatomy labs where we balance precariously on high stools praying we don’t fall face-first into the formalin.  Our reality is two junior students plus one senior student assigned to one patient in addition to the team that’s actually taking care of them.

Our reality is the super clever students answering all the questions meanwhile those of us who are not so clever mill around at the back of a ward round with 20-odd people without quite following the discussion. Our reality is a million different textbooks and the indefatigable expanse of the internet and consultants who constantly contradict themselves. Sometimes medical school is also a negotiation of egos.

Everyone knows one of these people.

Older consultants complain that the quality of the UWI medical student is declining. It’s true. When female med students show up in rompers to the hospital, or when a med student back-chats a consultant in exams, or when they can quote Bailey and Love’s back at you but don’t know the first thing about their patient’s procedures. These all represent a shift from previous standards, a downward shift.

But between the student and the consultant lies the administration. And the administration seems somehow disconnected from the goings on of the very people they administer to. Class sizes are uncomfortably large and the university responds by building basic sciences buildings big enough to fit everyone in. But the clinical spaces are the same size as they were five, ten, fifteen years ago.

There are not enough hospitals, not enough consultants who volunteer to be associate lecturers (I have to say volunteer because one common complaint about UWI is that they never pay anyone), and most importantly not enough patients.

We overwhelm everyone when we step onto the wards, every single time. There are only so many variations on ‘There are so many of you!’ that one can hear before one gets fed up.

‘You won’t all fit’,

‘You can’t all go at once’,

‘Some of you have to stay outside’,

‘Decide which one of you gets to do it’.

Please. It’s not our fault our class is this big. None of us have dropped out yet.

Yet despite the glut of doctors on the market and the increasing difficulties faced by medical students on the wards and in clinic the UWI doesn’t think to cut back on medical school entrants. They’re rolling out the red carpet for everyone. Everyone who can afford it, that is.

Grades aren’t a good enough criteria any more: everyone has Grade Is and IIs in CAPE, and co-curricular activities, and higher than 3.3 GPAs so now it’s the ability to actually afford medical school that separates the wheat from the chaff.

Actually, one does.

And once you can afford to get in, the long ago shift from essay questions to MCQs makes it infinitely easier to keep passing exams and make it to final year, MBBS and graduation. The standard of medical student isn’t the only standard that’s dropping here.

I wish our university would realize that trying to fit 500 medical students into a system with nowhere near that kind of capacity is like trying to pour 160lbs into size 2 jeans. The non-stretch kind. There is no stretch in this cotton, UWI.

We are the adipose pushing at your waistband, and one day the seams will burst.

UWI Bites Off More than They Can Chew (What Else is New?)

2015 will see the graduation of the largest medical class the University of the West Indies has ever produced. In the face of dwindling economic resources and rising costs of health care the 2015 cohort is a case of too many crabs and not enough barrels.

Last year the government struggled to find positions for the new batch of interns, having to stretch the usual quota of four basic rotations in internship year to include sub-specialties. This year, we have almost twice as many students graduating, provided we all pass final MBBS (and given our propensity to surpass the expectations of our administrators it’s very likely we all will). It’s begging the question: what are they going to do with us?

Rumours abound of strategies the government is trying to put in place to catch us all. But the catching will be clumsy if the rumours are to be believed. Some people murmur that a number of interns will be deferred from taking up posts until January of the following year. Others whisper that a shift system will be implemented allowing each intern to work for eight hours a day – this comes with the abolition of duties and (distressingly) the abolition of duty pay. But it’s all he said, she said, Chinese telephone.

Then there is the idea of the flexi-week. Recently decried by the Jamaica Medical Doctors Association, the flexi-week is a modification of the 40 hour work week that would allow employees and employers to come to individualized agreements on the distribution of working hours. The government wanted to implement this bill on April 1 but JMDA cried foul, admonishing Parliament for not holding discussions with key stake-holders (namely, doctors).

It is strange that on the cusp of entering the workforce, so much of the dialogue about the changes affecting that workforce is happening over our heads. We have a right to information that will affect how we live, work and do business in the upcoming years and it isn’t fair to withhold this information on the basis that we have not yet passed exams (if that is indeed the basis). Transparency is key or else, much like our transition through medical school, our transition into internship will be a rude awakening.

No one in my year batch knows just what awaits us on July 1, 2015. There are so many questions that need to be answered. Where will we be placed? How many hours will we have to work? How will we be paid? How will we afford to repay our loans?

UWI answers these questions with: We need a new hall of residence. We need a new faculty building. We need a new administrative building. We need an extension to the university hospital. As long as the input (students) generates revenue, the by-product (doctors) can muddle along as it pleases. Or doesn’t please, as the case may be.

Can we have the health ministry intervening to put a cap on the number of medical students the UWI can accept in any one year? There are so many disadvantages to large medical classes it would take an entire post to enumerate them all. Suffice to say the risk far outweighs the benefit.

Well Read Robin’s Anti-Medicine Tips Issue #2

People who can’t stand to see people suffering shouldn’t do medicine. This sounds counter-intuitive, but you’ll come to understand that everyone suffers and sometimes you can’t do anything about it.

People with sob stories shouldn’t do medicine. Your sob story ceases to matter once you get to the hospital. No one ever feels sorry for doctors.

People who are easily offended shouldn’t do medicine. Everything is offensive here: the patients, your colleagues, the smell of surgical wards. . .

People who are narrow-minded shouldn’t do medicine. The ability to think outside the box is indispensable to practicing in a third-world, limited-resource setting. The ability to treat all patients equally and without discrimination is also a useful asset.

People who are in it for the money shouldn’t do medicine. Seriously? Go do business. Who wants to spend 10+ years studying and then another 10+ years building your private practice so you can finally afford the house of your dreams? No one.

People with an aversion to normal social interactions should do medicine. From the awkward to the downright bizarre, medicine is chock-full of strange people discussing stranger things.