Tagged: medicine

Getting the specialist training job you want

When I was starting out in medical oncology my colleagues used to fret about there not being any jobs when we finished training. This wasn’t the case but it is starting to be true now. Although there are some early signs of exit block into consultant positions the emerging gap seems to be in advanced training positions. The reality seems to be that there are more potential trainees than jobs and this is starting to be a problem for all specialities. So if you want to progress from basic training to an advanced training position here are a few tips:

(1) Obviously pass the exams

(2) Treat every day as a job interview: you may not know who your future employers are

(3) Make your interests known but don’t be cocky or overbearing

(4) Do your due diligence – find out about the department you are interested in: talks to registrars already doing the job

(5) Pre-interview – meet your potential future supervisor

(6) Do something that makes you different from the rest of the pack: don’t just be somebody who has been to medical school and passed exams.

(7) Tell the interviewers about what makes you special

(8) Find out what types of question are asked at the interview and think of good responses

(9) At the interview always use personal anecdotes and experience in response to the questions

(10) Have a back up plan

The Art of War in Oncology

“Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat.”
― Sun Tzu, The Art of War

So a bit of brainstorming / mind dump ahead of a lecture on Saturday.

Oncology has come a long way in the last two decades. Some cancers, even when metastatic, have become chronic diseases. In particular this is the case for beast, colon and prostate cancer, and in some selected cases even lung cancer. This raises some important considerations about how oncologists approach the treatment of cancer.

In the past a die was cast and essentially the patient chose to take the poison (chemo) or not and if they took it and it worked then fantastic, and if not, well that’s the way it was meant to be.

Now, for many cancers, there are multiple lines of therapy. There are options for intermittent and maintenance treatment. And the paradigms are changing. In the past ‘systemic diseases’ were not treated with locoregional therapies but now it may be appropriate. We are moving to an era where the combination of targeted therapies and selective surgical cytoreduction, regardless of cancer type, becomes the norm rather than a situation where the rules are being broken.

So for the oncologist we must start thinking strategically about the goals of treatment.

If the aims change from achieving tumour response or prolonging life to cure (in the case of metastatic colorectal cancer) or achieving 5 year survivals in the metastatic setting then fundamentally different strategies are needed. Specific tactics we might pursue are maximal cytoreduction whether by chemical or surgical means, maintenance therapy, toxicity reducing therapy, planned treatment interruptions, immunotherapy and other maneuvers. Thinking not just what will be first-line therapy will be but looking ahead to the long-term strategy is required. Do you hold some treatments in reserve?

It is also important to think about chronicity and the effect it has on the whole person. I find my patients are stunned when I run out of conventional treatment options an yet they remain well, apart from the toxicities already inflicted. In this case there must be a lot of preparation for the eventual physical but not psychological surrender. It must be understood that many battles will be fought and won but the overall war could be lost but it doesn’t constitute giving up.

It must also be remembered that strategy is created in the midst of conditions of uncertainty. This can be communicated but only addressed by making life as normal as possible.

In addition to setting

We need a Incident Information Management System (IIMS) for Health Care Administration

When something adverse happens in hospital, for example, a patient is given the wrong medication, then we are supposed to log a report in the Incident Information Management System or IIMS. It is especially the case that this system should be used when harm to the patient is the result of the error. This is a good system but under-utilised and poorly designed – nonetheless we should continue to promote it.

We should in fact promote it’s extension to medical administration. If we really want accountability about the health care system, and in particular management of the budget, then we need an incident management system for the administrators. Let’s take the human resources department as one example. I have a potential employee for whom I could offer a job, No offer has been made even though the interview occurred 3 weeks ago. The hold up has been with the HR department and their need for more paperwork, etc, etc…..none of which was communicated as advice prior to the advertisement being released. Overall the whole process has been f’d-up, not to mention slow and expensive. So why shouldn’t I log this to IIMS.

Health care management in the Australian public health system is littered with examples of poor practice for which we should have an IIMS system……this is the way to achieve health care reform.

Things they didn’t teach in medical school: Part 34 Progressing through a career a.k.a getting older

It’s been a while since I did a “Things they didn’t teach in medical school” post but this week has prompted some introspection so let’s give it a go.

Two years ago my dad said he was retiring. Dad is a GP who, for as long as I can remember, worked 10-12 hour days, often 7 days a week. When he said he was retiring it meant he was moving from solo practice to a group practice and possibly working as few as 40 hours a week, but still doing on call well past standard retirement age.

But can this happen in speciality practice in 2013? A surgical colleague 10 years my senior (I’m about to turn 4) and I had a chat about this recently. The conclusion…..it’s hard.

The issue is maintaining the churn. This isn’t meant to disrespect our patients but the reality is we see a lot of them and it’s demanding work – physically, mentally and emotionally.

I look around at the people senior to me and the reality is that many of them, across many specialities, not just my own specialty of oncology, wind back their day-to-day clinical activities as they enter their fifties – a time which is really only in the waning part of their second decade of practice as a specialist. The combination of repetition and stress take their toll over time.

Now I don’t mean to say that this happens to everybody but I suspect it applies to a lot of practitioners.

So what to do about it – I think diversification of interests and practice is important. This doesn’t mean get a hobby but find a role in your profession that doesn’t rely on just seeing more and more patients. Find a research interest, become good at (and interested in) management or simply make enough money to retire early. Find something to keep you going to work in the morning.

And to the future registrars I’ll be interviewing on Monday……start thinking about these things early. Those that don’t will just burn out.

Medical consultations are a bit like elections: people vote for what they want to hear

Australia is in the midst of a Federal Election and for the next 3 weeks we are going to be hearing a lot of promises being made.

Reflecting on this election I’ve been thinking about the similarities between some of the medical consultations I conduct and electioneering.

Many patients come to me wanting be to impart hope. I might get them to live just that little bit longer by giving a new chemo or drug treatment. In political terms this is the promise of money. If you re-elect me I’ll give your electorate/community/organisation X million dollars to build Y & Z. Or I will cut a tax and reduce an expense.

But we (the electorate) are not iterate about these matters. We aren’t prepared to accept the real story…..that throwing some more dollars into the ring isn’t going to change much..it could ecen be wasteful. In the same way many patients are pursue the path that offers hope even though, in reality, the solution offered has little chance of changing the overall situation.

The politicians probably do actually understand the reality of the situation but they choose to play politics. The doctors also understand the reality of situations and either choose not to or are unable to communicate it effectively to patients.

The underlying problem in both circumstances concerns literacy. The economically literate would say you can’t increase spending without increasing revenue (aka taxes). Likewise the health literate individual would be able to acknowledge you sometimes run out of options.

Good Cop, Bad Cop

So I have a close working relationship with a surgeon where essentially I play bad cop to his good cop. The whole Hood Cop/Bad Cop concept is a method of interrogation. In our practice it is ostensibly around the good cop sending a positive message with hope and the bad cop (supposedly me) giving the bad message.

Well this is all around want people want to hear. It happens to be the good cop message.

But let’s recalibrate this. I probably am more pessimistic but the actual attitude I take is not of taking the ‘bad’ side but of being realistic. The statistics I quote are grounded in fact. I can’t and nobody can predict the future and some people have to have a good outcome and some have a bad outcome. Neither the good cop or the bad cop can predict the future but that can be honest about the chances even if they can’t tell who will do well and who won’t.

The realistic message needs to be heard when there is a situation where the gains can be modest and the trade-offs are high. Not everybody will take the odds offered: some people will end up hurt.

Vocational training has a nomenclature problem

Physician trainees having just completed their viva examinations are anxiously awaiting results and are deciding they want to do for the rest of their lives: they are about to embark on what is called vocational training. This is supposedly training for which these individuals have a special calling – like the priesthood.

In reality many of my peers and my juniors seemed/seem to have no idea what they have a vocation for and in fact base their sub-specialty on a variety of factors including exposure (it was the best of a bad bunch), lifestyle choices (financial , overtime/shift-work), brains/brawn (physicians vs. surgeons), and even parental expectation. As a consequence I often see fully qualified professionals who are not suited for their ‘chosen vocation’ for a whole variety of reasons ranging from technical incompetence, through to boredom and burnout.

I ultimately went down two vocational training pathways: medical oncology and clinical pharmacology. Notably I had always thought my vocation was psychiatry. I did a consultation-liaison psychiatry term for my option term in a New York cancer hospital and loved it but when I returned to do a general psychiatry term it really didn’t gel – I didn’t hate it but at the time I thought it was (and perhaps remains) flawed both in philosophy and science.

As it happened I did 2 terms each in medical oncology, haematology and gastroenterology and a term in palliative care and thoroughly enjoyed them: so what to I do now? – gastrointestinal oncology. Oncology lead me to drug development and an interest in quality care and this in turn lead to clinical pharmacology as a second specialty.

I could tell you why I like these specialties but I can’t actually tell you why I ended up here rather than performing cardio thoracic surgery (although I do often tell patients I could take them apart I just couldn’t put them back together again).

Unfortunately many trainees don’t get broad enough exposure to different disciplines in order to find their calling. In addition their modes of practice often don’t reflect what it is like as an actual consultant. For example many doctors get put off oncology because of the death and dying aspects as they only do inpatient work and no outpatient work – this is not a unique problem.

What I can tell you is this: get exposed to as much as possible and then do what you really enjoy and have found satisfaction doing. The success, career-wise, will follow-on and hopefully you’ll never get bored. In medicine never view the practice of medicine as a view to making money: if you take this pathway you need to remember the only way to make money is volume (i.e. lots of work). You’ll make more than enough doing what you really like and perhaps more than you expect. But if you really view financial gain as the reason for your ‘vocation’ then you chose wrong.

Finally don’t view a ‘vocation’ as being a singularity. First and foremost physician sub-specialty trainees need to remember that being a physician brings skills and opportunities to do things in the same way that law or commerce does.

What would you do doc?

One of the commonest questions I get asked as an oncologist is “what would you do doc?” or “what would you do if it were your mother?”

The more I get asked this question the more I wonder about its’ relevance as more often than not the patient/family goes with the option I wouldn’t necessarily recommend.

Usually this question is asked in the context that I am discussing the pros and cons of nth-line therapy for a incurable, metastatic cancer. The option of palliative care is always available and in many circumstances, in my view, is the best option. A lot of nth-line treatment options have statistically significant but clinically marginal benefit and being the expert who as looked after a lot of people I’d usually go the palliative care route as my own preference.

But this is my preference and it is informed by my world view. I think the flaw in the “what would you do doc?” question is that the real question is “what would you do if you were me?”….well the answer to that is I’m not you and I don’t actually know what your preferences are. I encourage patients to try and work out what kind of patient they are and what their preferences are: are they a “do everything possible person” or a “quality of life is my priority person”. Sometimes I already know the answer to this as I have known the patient for a long time.

The most important thing, providing you stick to the ‘do no harm’ rule, is that there is no medically correct answer but there is a right answer for the individual.

Effectiveness versus Efficiency in the Medical Consultation

One of the challenges in training registrars is trying to get over the apparent emphasis on the speed of consultation, or what you might call – churn. For doctors in clinical and rooms there is a set amount of time and a certain number of patients. You could argue that there might be more patients than a reasonable amount of time and yes one could take the approach that one will take as long as necessary to o deal with all the patient issues but reality dictates that if you take that approach you probably won’t actually see al that many people and the population might be less-well served as a result.

Bosses can get grumpy with their registrars is they only see a few patients in their clinic and the clinic runs over time. Equally so the registrars might feel they are taking too long or perhaps not being thorough enough.

Rule 1 should be that every consultation isn’t a so-called long-case. I like to say…if there is nothing wrong then there is not much to say. Rule 2 should be that the focus is on effectiveness not efficiency. By this I mean – did you identify and sort out the problem? You can still this in a timely manner – you just need to adjust the pace to the circumstances. In my experience patients don’t like to be rushed but on the other hand they are more concerned with having their issues addressed and if you can do this the time it takes is of lesser importance. Flowing on from this then Rule 3 must be ‘deal with the most important concern to the patient’ – this is perhaps the hardest part. For starters what the doctor thinks is important and what the patient thinks is important isn’t always the same. Secondly what the patient thinks is important isn’t always transparent….this is the ‘there’s one more thing doc’ discussion.

So in summary – work out what’s important and deal with it and move on. This is effective and efficient consulting for a resource poor reality. In other words, until we get more resources to support whole person care and the time-unlimited consultation ‘Don’t sweat on the small stuff’

A turn of phrase in oncology

Communication in medicine and perhaps especially in cancer care rests on the interpretation of words.

Today I had to deal with the retort ‘but your colleague said that the chemotherapy I had was the best available for my cancer….so isn’t what you are offering me now not as good’.

So let’s strip this down. ‘The best available’ comes with caveats – the best available chemotherapy (just ignoring some of the new drugs) for melanoma has between 5 and 15% chance of shrinking deposits of melanoma. It is clear that ‘best available’ – at least in the eyes of the prescriber – is not the same as saying the treatment is effective for everybody. A treatment can be the best we have for all-comers but in reality the overall results can be pretty poor. The big problem is that most treatments don’t work for everybody: I can only get around this by saying that a treatment is the best option (compared to other options) and that even though a treatment is the ‘best’ for all-comers there is no way of predicting, for most drugs, which person will be the one who benefits.

Because of these vagaries we also need to be aware that just because one treatment didn’t work it doesn’t mean another might not – it may be that second treatment is better than the first – we just don’t currently have the means to predict which was the right treatment in the first place.

The trick for oncologists and other physicians – pick your words carefully – or take the time to explain what you mean.