On fat patients

By: Umangjot Bharaj

There is significant controversy when it comes to physicians commenting on their patients’ weight and lifestyle choices. Not only is weight loss especially difficult to achieve, and even more difficult to sustain; repeatedly telling patients to loose weight often hinders weight loss. Existing in a society that constantly shames and vilifies fatness, and often treats fat people as second-class citizens, fat patients become hypersensitive about their weight and any comments about it. In this context, a physician telling a fat patient to lose weight, when done without nuance and as a cursory addition to management plans, can have a very negative impact on the patient.

The Body Positivity Movement and Physicians

Cue the body positivity movement. Body positivity is essential for the society we live in: it represents and advocates for the idea that our worth is not determined by our size or our health status, and that to discriminate, shame, and vilify people based on their size, is unacceptable. Where body positivity loses its focus, however, is if it suggests that physicians should not tell their patients to lose weight ever.

While I agree that health cannot be defined and constrained to something as simple as body size alone, and that each individual has a right to define health for themselves, I think that physicians still have a right to encourage, motivate, and influence their patients toward healthier habits. HIV patients are stigmatized, but doctors don’t stop encouraging healthy sexual practices to HIV patients. Similarly, fat stigma does not mean that excess weight does not have a correlation with bad health outcomes. Excess weight complicates pregnancies, deliveries, and surgeries in general, making them riskier, and has been linked to many conditions such as metabolic syndrome, sleep apnea, and osteoarthritis of the knees. Thus, to suggest that a physician never comment on weight as a relevant factor in causing or exacerbating a patient’s condition is too simplistic and does fat patients a disservice.

It is however, important to accept that physicians are in a unique place to comment on the lifestyle choices of an individual. As a society, we don’t comment on people who choose to smoke, but as physicians(-to-be), it is our role to influence and motivate our patients toward healthier habits. Similarly, physicians have a responsibility toward their fat patients to talk about healthier life choices if they, in their clinical judgement, think that a patient’s weight or health is being affected by their lifestyle choices.

This is not to say that doctors have done no wrong to their fat patients. Research indicates that primary care providers do not build rapport and emotional bonds as strongly with their fat patients as they would with their non-fat patients. Another study found that physicians are more likely to prescribe more tests while spending less time with the patients themselves. There is a tendency to blame patients’ weight for all of their symptoms and in the process not recognizing other diagnoses or undertreating the other recognized diagnoses. Often, weight loss is prescribed as the treatment for all of their symptoms, even though patients would benefit from other medical interventions for their comorbid conditions.

A Patient’s Experience

One patient experience can illustrate what patients face when they go to see their doctor. This patient recounts myriad experiences of mistreatment and discrimination from health care providers: from being told that it was not possible for her to have a normal blood pressure (and having it re-taken 4 times), to being told to lose weight as a remedy for her anxiety and even her ear infection. There are even examples of doctors putting weight limits on patients they would accept: more than 250lbs and you wouldn’t be accepted by certain OBGYN. Fat patients recount experiences where doctors wouldn’t touch them, wouldn’t examine them, wouldn’t ask questions, or would refuse to order tests, refer to specialists, or write prescriptions.

These factors significantly complicate the discussion surrounding weight loss reduction. However, these are not reasons to justify that discussing weight reduction is always detrimental. Instead, they are reasons to introduce the idea of discretion and nuance in handling sensitive conversations such as those surrounding weight reduction.

In caring so deeply about our patients’ physical health, we cannot forget about their mental well-being and sanity, especially because the two are so interconnected and intertwined. For patients’ that live in a society that constantly reminds them that their weight makes them inadequate, physicians reiterating that only reinforces a vicious cycle of self-loathing, fuelling feelings of worthlessness. In patients that are battling mental health issues such as depression, anxiety, eating disorders, and substance abuse disorders, feelings of worthlessness and self-loathing can fuel into and exacerbate their mental health conditions. Perhaps most disturbing is that it discourages patients from seeking health care services at all.

Moving Forward Together

Weight loss discussions are discussions that need to happen in the context of a longitudinal relationship, or in the context where the support of a longitudinal relationship is possible. As well, these discussions require participation from the patient, and should empower and give control back to patients who likely feel disenfranchised by their inability to lose weight. There needs to be discretion as to when and how to approach the subject. This means that if a lot of times you have to ignore your patient’s weight problem because it’s not the right time or setting, then so be it. Finally, these discussions must take into account that simply prescribing patients with lifestyle changes often underestimates the influence of other contextual factors that can impact weight loss.

There is some discussion from practicing physicians about the need to reframe the conversation: instead of being preoccupied by a patient’s weight, physicians can simply encourage all patients to develop healthy lifestyle habits and behaviours. There is research to support this as well. In one study comparing the effectiveness of a weight-normative approach to a weight-inclusive approach, the latter was found to be much more effective and have better health outcomes in all domains, ranging from physical to behavioural to psychological.

Part of the challenge of being an effective physician is the art of difficult conversations. Running away from a conversation because it is difficult is neither productive nor useful to our patients. But by finding ways to have important conversations in a productive manner, we are able to better serve our (future) patients and be better physicians.  

Author: Umangjot Bharaj

Umangjot completed her Bachelor in Health Sciences from McMaster University. In recent years, she has gotten quite involved with social justice work, and has a significant interest in advocating for marginalized populations whenever possible. She loves reading and writing in her free time, and enjoys creating healthy versions of traditional recipes.
Photo Credits: Keto HC, Creative Commons 

Learning to breathe again

By: Jessica Garabon

Every so often I have to learn to breathe again…

It sounds like such a silly statement.  Breathing is something that we are innately programmed to do. But when I was asked to describe my experience with depression and generalized anxiety disorder, this was the only phrase that began to describe it. It is like learning to breathe over and over again.

My struggles with mental health have been present for most of my life. However, it wasn’t until three years ago that I could put a name to what I was experiencing – when I was diagnosed with both generalized anxiety and major depressive disorders. I had experienced many of the symptoms encompassed in these two conditions since I was a child. But because there was nothing medically “wrong” with me, I was labelled as moody, overly emotional, or disruptive. For the next several years of my life, I internalized the thoughts and feelings that I was experiencing as myself just overreacting or getting worked up over nothing. I placed an inordinate amount of blame on myself and resolved to move past these scenarios and just “be better”.

Throughout high school and university, the anxiety and emptiness that I experienced were magnified. The funny thing was, if you asked anyone in my life from my close friends to casual acquaintances, they would describe me as being incredibly happy all of the time. Sure, I knew that away from the gaze of others I would have bad days or weeks, but I would also have periods of unequivocal happiness where I couldn’t wait to see what the future would hold for me, so how could I possibly be depressed? Over time, the periods of depression and crushing anxiety began to grow longer and the moments of happiness became increasingly less frequent. Even when you need it the most, reaching out for help is an incredibly difficult feat. I found this to be especially true because I didn’t know how to define what I was experiencing yet. Was I over-reacting? Was this something that everyone goes through in university? How could I ask for help when I didn’t even know what I needed help with? With time, I finally made the decision to reach out to my doctor. Being formally diagnosed gave me a strange sense of closure. I could finally put a name to my illness. A name that made me feel even the slightest bit that my struggles were validated. I felt excited and hopeful about my future. I knew what was wrong with me and now I could go out and fix it. Like I have found time and time again, life just isn’t that simple.

When I started medical school, it was meant to be the happiest time in my life. I had worked for it for years and dreamed of it for even longer. I had always believed that my depression and anxiety were centered around my unhappiness with where I was at in life. If I could accomplish more, do better, be better then I wouldn’t have this weight hanging over me. In a one-year period I married my high school boyfriend, completed my master’s degree, and was accepted into medical school- everything I had dreamed of was finally at my fingertips. At this time, I thought that I would finally be free of the depression and anxiety that had haunted me since I was a child. I was exactly where I wanted to be in life. But as I sat there during my medical school orientation, I felt the familiar pain of not being able to breathe.

From that moment on, I fell into a depression deeper than I had ever experienced. Depression and anxiety have become colloquial terms that are thrown around to superficially talk about mental health but being suicidal isn’t something that is often spoken of. Suicide is an uncomfortable topic that is often shied away from in conversations about mental illness, but it is a very real and prevalent issue, especially within the medical community. Because of the prevalent stigma that comes along with speaking of being suicidal, I was afraid to reach out and ask for the supports that I needed. How could the girl who was always smiling and supportive, the person that classmates would go to for advice, the student body president be suicidal or suffering from depression? How could I ever be the doctor when I was also the patient?

In starting medical school, I had endeavored to keep my illness a secret. I believed that if my new peers discovered what I was hiding, the imposter syndrome that I so often experienced would be validated by all of those around me. I began to worry about how dealing with mental illness would affect my future career as a physician. But I have decided that I refuse to be part of a healthcare system where I will be stigmatized for being both a physician and patient.

My story is not special, and it is not unique. There are an endless number of people like me, who have experienced this kind of hardship and still persevere every single day. I’m still sick, and I believe that these are issues that I will continue to manage for the rest of my life. But my perspective on my illness has changed. I’ve started talking more openly about my mental health with those in my life. Normalizing my illness has given me the strength that I need to learn how to breathe again one day at a time. I’m slowly learning to trust others and that I don’t need to carry the weight of my illness all on my own. I have built the most incredible support system, and I could not be more thankful for the endless number of people that have demonstrated kindness and compassion and friendship throughout my journey. I take the medications that I need to allow my brain to function normally, and I continue to work on myself every day with the help of an incredible psychiatrist who is well-versed in physician and trainee mental health. I’m not okay today, but I know that I will be one day. I know that I have a future with love and hope and happiness. I know that my experiences with depression and anxiety will help me to be a more compassionate and empathetic doctor. I know that one day I will breathe freely again.

As I continue to move forward in my journey, there are a number of realizations that I’ve made that have contributed to my recovery. First, I have spent most of my life searching for my purpose; seeking out greater meaning in the world and the one ultimate source of happiness to light a spark inside me and show me why I’m here. This is something that I have spent years searching for but have never found because life is just not that simple. One of my closest friends has helped me to realize that life is not black or white. Good or bad. Pure or evil. Just as happiness isn’t one grand event or nothing at all. She has shown me that happiness isn’t a destination or one occurrence in life that we get to experience. Happiness, as cliché as it may sound, is a collection of tiny moments in everyday life than can bring joy and appreciation and love. These moments can be as simple as having coffee with a friend in the middle of a hectic day, spending an hour at the park with my dog, sleeping in without an alarm, or hearing the purest and most magnificent belly-laugh of my husband. Any of these moments alone are not momentous or overly significant, but together they form a life filled with purpose and meaning and value and hope.

Now, during difficult days, there is a quote that I like to remind myself of by one of my favourite authors Jamie Tworkowski:

“Your questions deserve answers, but just as much, you deserve people who will meet you in your questions. Some answers will take years. Some answers will take a lifetime. The questions often weigh so much. The good news is you don’t have to carry them on your own. This life, our healing, our recovery, it is certainly a journey. What a miracle that we don’t have to do it alone.”

Despite the difficulties and uphill battles that I still continue to face. Despite the struggle of facing a world that continues to stigmatize and cower away from my illness. Despite the beautiful and wonderful days that can be interrupted unexpectedly by a familiar sense of being unable to breathe, I am not alone. What a miracle that I don’t have to do this alone.

Author: Jessica Garabon

Jessica completed her B.Sc. in Behaviour, Cognition, and Neuroscience at the University of Windsor and her M.Sc. in Neuroscience at Western University. She is the incoming Hippocratic Council President and a proud co-founder of Proaction on Mental Health (PRO-MH). Jessica is passionate about narrative medicine and being an advocate for physician and trainee mental health. She loves travelling and coffee and is a fierce supporter of the Oxford comma.
This post was inspired by Proaction Mental Health, a new social 
movement created by Schulich medical students to tackle the stigma
of mental health, and to provide a strong supportive community among
future healthcare professionals. Follow them at @proactiononmh on
Instagram and Twitter!
Photo Credits: Breathe, Creative Commons 

The elixir of the gods is here. Or, it was. The tale of Ambrosia, LLC.

Disclaimer: We started writing this post back in January, right around when Ambrosia officially began operating in the US. Since then, Ambrosia has suspended its work following concerns from the FDA. Its former website domain, ambrosiaplasma.com, is no longer live. Simply put, Ambrosia seems to have disappeared. And though Ambrosia may be out of the picture, if we’ve learned anything whilst writing this piece, the quest for immortality has a long history. Ambrosia and its founder Jesse Karmazin are not the first and certainly won’t be the last to tout the transfusion of “young blood” to combat disease and aging. And with the scientific jury still out on whether or not this is even possible–let alone safe–the importance of this piece cannot be overstated. As a result, we have therefore decided to leave this piece in its original narrative form. We hope you enjoy reading.

Original Piece:

Humanity has been fantasizing about an elixir of youth since the Mesopotamian Epic of Gilgamesh. Have we finally found it in an obscure blood transfusion startup? Ambrosia, a company run by the Stanford-trained Jesse Karmazin, claims to have begun operations in 6 US cities. Its mission? To provide customers with the blood of young people. Its claims? To rejuvenate its customers through the use of this “blood drug.”

This, for the cool price of 8,000 USD for 1 litre or 12,000 USD for 2 litres. And while the word “ambrosia” may have its roots in the food or drink of the Greek gods conferring longevity and immortality, Ambrosia, LLC, is anything but.

What is Ambrosia?

Taking a tour of Ambrosia’s recently updated website, one is immediately reminded of other similar, Silicon Valley-esque sites. It’s aesthetically pleasing. It has pictures of hikers, lush fields, and tastefully decorated shelves–all of the things you want your company to stand for. What Ambrosia’s site doesn’t have is information. The entire site has just 160 words, including the “science” used to back up this treatment modality (more on that later). Towards the end of the site, visitors are directed to a PayPal payment menu with two options: 1 L or 2 L of young people’s blood. Even in our minimalist culture, this website seems to be a little bit sparse.

So, to learn more about what Ambrosia is, what it does, and how it started, we went straight to the source: Jesse Karmazin, a Stanford Medical School graduate (but, still without a medical license), founded Ambrosia in 2016. Since then, he’s kept a relatively sparse presence on the internet while building his company. Other than attracting the attention of the notorious Silicon Valley investor Peter Thiel, basic Google searches of Karmazin yield nothing more than articles about Ambrosia and his LinkedIn profile--which is where we chose to reach out to him. He answered, and kindly agreed to let us cite him here.

To gain a better understanding of where the blood for these transfusions is obtained, we first asked Mr. Karmazin what controls and definitions they used for these transfusions. Said Jesse, “the blood is obtained from blood banks in the US, and is tested according to FDA requirements,” going on to later describe that “[we] define young blood as 16-25… blood banks do keep track of donor ages.” When asked about that science behind what Ambrosia does, things got a little more abstract. While Jesse did say they would be publishing the results of their clinical trial later this year, he did not give us any more specifics about the outcomes of the study. He did, however, mention that “we’re seeing improvements in illnesses such as Alzheimer’s and other age-related disorders, as well as other things associated with aging, like energy, muscle strength, memory, skin quality, joint pain, etc.” In addition, much of the existing literature Jesse shared with us as the basis of Ambrosia’s work has only been done on mouse “parabiosis” models and rather than with transfusions (an important distinction we’ll get into later) which has only further clouded the legitimacy of this science. This brings us to the centre of the debate about Ambrosia: is there any science to back this up?

What’s the science?

The use of younger people’s blood to improve one’s well-being and prolong life is not a new idea. In fact, history is littered with tales of larger-than-life figures seeking mortality in the blood of the young. Pope Innocent VIII (ironic, we know), who claimed the Holy Chair in 1484, quickly saw his health deteriorate. Following a stroke in 1488, Pope Innocent VIII was desperate and barely clinging to life. So, in attempt to thwart death, Pope Innocent VIII looked to the youth:

And while this experiment with the use of young blood to cure his ailments ultimately failed, the dream of such a therapy has lived on.

Enter Jesse Karmazin.

Jesse Karmazin, the CEO and Founder of Ambrosia, stated his interest in the field of parabiosis started back in 2013, from a study in mice that suggested that some aspects of aging could be reversed when older mice are transfused with younger mouse blood. In this study, researchers identified a compound in blood, GDF11 (a member of the TGF-B family), that declines with age, and suggested that restoration of this compound could reverse age-related cardiac hypertrophy. Though interesting, these results were obtained through a less-than-ideal procedure for humans called parabiosis, which involves literally sewing older mice to their younger counterparts to connect their vasculatures for up to 4 weeks. I don’t know about you, but spending 4 weeks sewn to someone else seems like a high price to pay for restored youth.

The problems with Ambrosia and parabiosis don’t stop there. Ambrosia’s now-complete clinical trial, as registered at ClinicalTrials.gov, yields some serious red flags. Despite still not publishing any results from the trial, the description of the trial states an actual enrolment of 200 participants above the age of 35 that received infusions of plasma derived from young donors between the age of 16-26. In order to assess “spectrum of physiologic pathways with evidence-based connections to aging,” Ambrosia’s trial description also sets out primary outcomes to track a panel of age-associated biomarkers before and after treatment. Such biomarkers include various immunoglobulins, chemokines, cytokines, and lipoproteins that are linked to “specific disease states”. Throughout the trial, participants were also said to have had their “organ function [which will be] specifically measured includes the liver, bone marrow, kidneys, pancreas, muscles, cardiovasculature, cerebrovasculature, and the thyroid. All of this, without any data to show or science to back up their claims.

What are the ethics?

First and foremost, Ambrosia’s commodification of blood undermines the altruism-based framework of both clinical research and blood donation. In its previously-discussed clinical trial, Ambrosia was charging individuals 8000 USD just to participate in a research study with no scientific merit in humans.

As they exist today, blood donation and clinical research both tend to rely on volunteers. Some donors in the U.S. are compensated, however, with donors receiving up to $50 per donation, and some research participants also being compensated for their time. The rationale for compensating volunteers for their time and donation exist in some jurisdictions to avoid coercing volunteers into participation, while alleviating the sometimes-significant barriers to participation.

In either case, by selling blood plasma that has been collected either from volunteers or compensated participants for a staggering $8000 per litre, Ambrosia has commoditized this precious resource in a way that does not reflect how the medical community has chosen to encourage blood collection. Allowing participants to participate in a clinical trial by paying to do so subverts the prevailing framework for medical research where participants are encouraged to participate out of good will. How this trial was approved by a research ethics board remains unclear to us.

In the realm of ethics, a secondary concern also comes to mind: blood is a scarce resource. By diverting blood that would otherwise go to saving lives towards an unproven intervention, people who have proven medical need for blood transfusions may be disadvantaged. Furthermore, should this treatment option become more mainstream and cheaper, already low stockpiles of blood for donation will become even more strained.

Conclusion:

The Epic of Gilgamesh is an ancient Mesopotamian odyssey written in the Akkadian language, and chronicles the adventures of Gilgamesh, the king of the city state of Uruk. While the details of the story are not pertinent to this piece, the ending most certainly is. Upon meeting Utnapishtim, the survivor of the Babylonian flood, he is told the story of the flood and is shown where to find a plant that is capable of everlasting life. Upon finding the plant, Gilgamesh lets his hubris get the best of him, letting his guard down only to have it seized and eaten by a serpent. Gilgamesh never succeeds in his quest for immortality, and returns to Uruk dismayed and defeated.

This story is not unlike that of Jesse Karmazin and all of the other men and women before him who have dreamed of youth and immortality. Indeed, it is a quest that has lasted for all of time, and seems poised to last for the foreseeable future. And like all those who ventured on this quest before it, Ambrosia, LLC, will hopefully be no exception to the trend: a victim to its own hubris. With dubious scientific claims, an uncomfortable ethic basis, and leader unwilling to see right from wrong, it is clear that Ambrosia poses a clear and very real threat to society and itself. Only time will tell how far it goes; and, without serpents to steal its stockpiles of donor blood, what it will take to stop it.


Author: Zach Weiss

Zach Weiss completed his B.Sc. in Microbiology & Immunology at UBC in Vancouver. Over the years, Zach has become increasingly fascinated with the world of politics and policy, and has spent way more hours listening to political podcasts than he’s willing to admit. As a first-year medical student at Schulich, He’s particularly interested in merging his interest in politics and policy with his growing medical knowledge to advocate for and bring awareness to issues that are often overlooked.
Photo Credits: Cava Photos 

Part 2: The Philosopher Emperor

By: Eric Di Gravio

Marcus Aurelius: In the Capitoline Museum

In my previous blog post, I started to describe how Marcus Aurelius thought that we should face all our struggles without complaint. But where does the strength to do this come from? Let’s continue with what Marcus thought the answer to that question was:

You have power over your mind-not outside events. Realize this, and you will find strength.

A strong person, according to Marcus, recognizes that strength comes from within. It’s in our thoughts and in how we choose to perceive the world around us. The Stoic philosophy that Marcus learned as a young adult taught him that no events which happen are in themselves evil, it’s only our perception of them that is evil. If we have the inner fortitude and belief that we will overcome whatever hardship we are facing, then that is the source of true strength. Marcus explains this well and takes it a step further when he says:

Apply this principle: not that this is a misfortune, but that to bear it nobly is good fortune.

Again, it all comes down to perception. Question yourself: Is this difficult task or unfortunate event really a bad thing, or is it simply an opportunity to make myself better? If we begin to face our problems with this in mind (which I understand is no easy feat), then we will be facing it with all the strength we can muster, and we can’t ask for much more than that.

One last passage on this topic that I found particularly powerful is the following:    

Thou sufferest this justly: for thou choosest rather to become good tomorrow than to be good today.

Medical school and being a doctor isn’t going to be easy, it was never going to be. But all the exams we write, the facts we memorize, the patients we will see and inevitably, the mistakes we will make along the way, are simply necessary steps to make us better people, and doctors of tomorrow. 

What Motivates Us

In his Meditations, Marcus spends much time discussing the purpose of his life. As he mentions over and over again, he finds the praise of others (remember that he was considered a god), the pursuit of fame, glory and wealth all as hollow things. His line of thinking is, if everything including yourself is transient, then what is the point of achieving fame and glory when people are bound to forget you eventually? As Marcus says:

What is even an eternal remembrance? A mere nothing.  What then is that about which we ought to employ our serious pains? This one thing, thoughts just, and acts social, and words which never lie, and a disposition which gladly accepts all that happens

This was not meant to be some doom and gloom statement about how we are all going to die and nothing matters. Instead, by constantly repeating statements like the ones above, Marcus was attempting to keep himself well-grounded and not to get caught up in all the extravagances that many prior, and certainly many later emperors did. He was reminding himself then, and us now, what the truly important things in life are: acting justly and for the common good, and being thankful for what life has given you. Marcus then goes a step further and says:

Have I done something for the general interest? Well then I have had my reward. Let this always be present to thy mind, and never stop doing such good.

Here again, Marcus is reiterating the fact that acting for the common good is the highest reward one can receive, even if its not appreciated at the time. Indeed, it is the very act of working for the common good that should serve as our motivation for everything we do. In other words, the most important thing is being able to go to bed each night with the satisfaction of knowing that we helped someone that day, and that that act in and of itself should be all we need to keep us satisfied and motivated.

Final Thoughts

I couldn’t help but wonder what Marcus would say if now, almost 2000 years later, I were to ask him for one piece of advice about how to be a good person and leader. But then I came across this passage in Meditations that I think answers that question pretty clearly.

Waste no more time arguing what a good man should be. Be one.

Alright then Marcus, point taken. I guess he would say that we all already have it in our hearts what it takes to be a good person and doctor, we just have to have the strength and dedication to do it.

A note on translations:

Since the Meditations are essentially Marcus’s reflections on the philosophical school of thought called Stoicism, and the vast majority of philosophical teachings at the time were written in Greek, Meditations too was written in Greek (even though Latin is the language most commonly associated with Ancient Rome). As in any work of literature originally written in ancient Greek, there are various different translations which all have the same essence, but with slightly different wording. Therefore, if you look up these quotes online or have heard/read a slightly different quote than one I have used here, note that it is simply a different translation of the same piece of work, and hopefully you can see that it captures the same meaning.

Select Quotes from Meditations:

  • “And though wilt give thyself relief, if thou doest every act of thy life as if it were the last, laying aside…discontent with the portion which has been given to thee.”
  • “Short then is the time which every man lives, and small the nook of earth where he lives; and short too the longest posthumous fame”.
  • “Which of these things is beautiful because it is praised, or spoiled because it is blamed? Is such a thing as an emerald made worse than it was, if it is not praised?”
  • “The best way of avenging thyself is not to become like the wrongdoer.”
  • “Let not future things disturb thee, for thou wilt come to them, if it shall be necessary, having with thee the same reason which now thou usest for present things.”
  • “No man can escape his destiny, the next inquiry being how he may best live the time that he has to live.”
  • “Look within. Within is the fountain of good, and it will ever bubble up, if thou wilt ever dig.”
  • “Neither in thy actions be sluggish nor in thy conversation without method, nor wandering in thy thoughts…nor in life be so busy as to have no leisure.”
  •  “This too is a property of the rational soul, love of one’s neighbour, and truth and modesty.”
  • “If it is not right, do not do it: if it is not true, do not say it.”

Author: Eric  Di Gravio

Eric is a second year medical student at Western University. He also completed his BMSc in Biochemistry of Infection and Immunity here at Western. Eric is a self-proclaimed history buff but also enjoys basketball and attempting (and failing) to match his grandmother’s cooking skills.
Sources: 
Photo Credit: Marcus Aurelius, Creative Commons

The Philosopher Emperor

By: Eric Di Gravio

Equestrian Statue of Marcus Aurelius, Rome

Part 1

I have always considered myself a history buff. I will admit, I still pride myself on my collection of books accumulated from childhood that fill my room. While history has always been a hobby of mine, as I got older, I found myself finding inspiration in the lives and exploits of men and women throughout history; from ancient Mesopotamia to the global conflicts that shook our world in the 20th century. Since starting medical school, I now find myself reflecting on what it means to be a ‘good doctor’ and have begun to see the stories of these same men and women in that new light. Recently, I have been on a bit of an ancient Rome/Greece binge and in doing so have come across (again) the writings of the Roman Emperor Marcus Aurelius (yes, the old emperor in Gladiator). For reasons I will endeavour to share with you, I think that we have much to learn from this once beloved emperor about how to be a good person and by extension, good doctors. But first, let us start with some background.

Importance of the Roman Empire

Ask someone to blurt out the first thing that they think of when you say “Roman Empire” and chances are it will be the Coliseum, gladiators, togas or Julius Caesar. But the Roman Empire has given us so much more than a trendy tourist hotspot, movies with Russel Crowe fighting sadistic emperors, toga parties or Caesar salad (spoiler alert, Caesar salad has nothing to do with Julius Caesar). Rome is everywhere, from the ruins left behind to the borders of our modern-day countries, even to the organization of our governments. But what can we learn from the people, places and history of 2000 years ago? While that is a question that countless classical historians have spent their lives trying to answer, what I add is this: the world of the ancient Romans that Marcus Aurelius knew was not so different from ours. Just like us today, the ancients worried about the economy, national security, religion, politics, healthcare and countless other existential crises.

Who was Marcus Aurelius?

Born in 121 AD in Spain, Marcus Aurelius was adopted by his uncle and future Roman Emperor Antoninus Pius as his son and heir to the throne. Upon becoming emperor after the death of Antoninus, Marcus devoted much time to reforming the law to be fairer for the poor and powerless, promoting free speech, stabilizing the armies and boosting the economy. For this and for his famously humble and simple personal life, Marcus is known as the last of the five “Good Emperors” and the last emperor of the “Pax Romana (Roman Peace),” stretching from the first emperor Augustus all the way to Marcus, a period of about 207 years. While there has certainly been some romanticising of this era in Roman history, there is no doubt that these years saw Rome at the height of its power in terms of economic wealth, territorial extent, military success and relative peace within its borders. After the death of Marcus, the Roman empire fell under increasingly more despotic emperors, witnessed decades of civil war and economic recession, and never truly regained the same power, influence and wealth that it had enjoyed previously. 

Marcus’ biggest claim to fame however remains his Meditations. While by day Marcus was fending off the invasion of the Germanic “barbarians” into the Roman empire, by night he was writing in a personal diary his daily thoughts and feelings. Never intended for the public eye, Meditations reflect the inner thoughts of Marcus at his most vulnerable and dark times while he reflects back on the teachings of the Stoic school of philosophy that he had learned as a young man. Preserved after the death of Marcus, this diary allows us a glimpse into the thoughts of one of the most humble and down-to-earth people to ever live, let alone be an emperor. Reading his work, you get no hint that this was written by one of the most powerful men, in one of the most powerful empires ever to set foot on the world (considering that Roman emperors were basically treated as gods on Earth). Just like many people before me, I too have found inspiration in the words of Marcus and think that there is something in them that can give us some insight into how to be good people, and by extension, good doctors.

Following then, is a collection of some of the lessons I believe we all can learn from Marcus.

On Handling the Tough Times

Even though he was an emperor, Marcus was no stranger to struggle. Death loomed heavy over his head as he witnessed both the death of many of his children, and also the eventual death of his wife. Even Marcus himself was a sickly man, (although we don’t know his exact ailment today) his seemingly impending death seemed often to be on his mind throughout Meditations. Apart from personal struggles, Marcus also had an entire empire to worry about. Early in his reign, he was fending off invasions from the Parthian Empire in his Eastern provinces. Even after a Roman victory, there was no time for rest, as very soon after there was a plague (likely smallpox) that ravaged the empire, closely followed by an invasion of Germanic “barbarians” along the northern border… and it keeps going. 

The biggest lesson I think we can learn from Marcus in this regard is best summarized by this passage in Meditations:

‘A cucumber is bitter.’ Throw it away. ‘There are briars in the road.’ Turn aside from them. This is enough. Do not add, ‘And why were such things made in the world?’

            The lesson that Marcus has captured in this passage is the fact that hardships will happen to everyone and there is no use thinking “why me?”. Marcus would say that instead of becoming upset that such things have happened, we should focus our energies on solving them and moving forward. Thoughts of “why me” or “this is such a waste of time, why do I have to do this” are in themselves “wastes of time” and don’t help solve the problem or complete the task at hand. 

But where does the strength to do this come from? Check out my next blog post to learn where Marcus thought the answer to this question laid. 

Author: Eric Di Gravio

Eric is a second year medical student at Western University. He also completed his BMSc in Biochemistry of Infection and Immunity here at Western. Eric is a self-proclaimed history buff but also enjoys basketball and attempting (and failing) to match his grandmother’s cooking skills.
Sources: 

Let’s open up the conversation about death

By: Christopher Creene

I’ve been thinking about my Dad a lot recently. Another February 4th has come and gone, and this year it marked 8 years without my Dad. When asked about my parents, I find myself speaking about my Dad in present tense as if he is still with us, failing to mention that he passed away from a heart attack soon after we moved to Canada.

Why?

Don’t get me wrong – I want to talk about him. I want to share fond memories of him, and laugh about the antics he used to get up to. But over the past few years I’ve become increasingly aware of the ‘social taboo’ that exists around death. People get awkward and don’t know where to look when you talk about someone close to you dying. It makes people feel uncomfortable. So I’ve learned not to bring it up, to pretend it didn’t happen. I’ve met all kinds of wonderful people since moving to Ontario last year, but in that time I have only told one person about the death of my father. It’s with such regret that I feel I need to hold back on talking about the man who made me who I am today. He was a wonderful role model to my siblings and I, and a dearly loving husband to my mother. I have such pride in saying that he is my father.

Whilst writing this blog entry, I started to wonder how other people felt about this topic after losing someone they love. I reached out to one of my best friends, an incredible guy who I’ve known for many years now. His younger brother was tragically killed by a drunk driver 3 years ago. This is what he had to say:

“In my experience, I feel that those who aren’t your family don’t want to hear about your hardships. I think that’s mainly because it makes them feel sad, and it makes them worry that YOU could become upset, at which point they’d have to console you. Also, in general I don’t want people to pity me. I want people to do/say nice things for/about me not because they pity me, but because they respect me.”

His words perfectly describe what I’m trying to get across, and it was interesting to hear that I am not the only person who feels this way.

I’ll admit that prior to experiencing loss myself, I responded to death in a similar way. It made me uncomfortable, and I would avoid talking about it to prevent others from becoming upset. I felt that because I couldn’t relate, any words of comfort that I provided would lack authenticity. This is one of the main reasons why I felt that it was important to write this blog entry, as a way to share my personal experiences as someone who now understands, and to give advice on how I think we should be addressing the subject.

So how do you respond to someone sharing their grief with you?  How can we normalize death and open up the conversation?

The major misconception that I think needs to be cleared up is that you should avoid talking about someone’s loss because it will make them upset. Although different people grieve in different ways, my general experience has been that people want to talk about a lost loved one. By talking about that person, you keep their memory alive. The next time someone shares this personal part of their life with you, don’t shy away from the topic. Ask them ‘What was she/he like? What’s your favourite memory with them? What were his/her hobbies?’. Personally, I love talking about my Dad – it helps me keep him close.

Of course, sometimes I do get upset when talking about him. But that doesn’t mean that you should avoid bringing it up! In writing about the death of a close friend, Alfred Lord Tennyson wrote “’tis better to have loved and lost than never to have loved at all”. When someone dies, the family and friends left behind don’t want to just pretend that person never existed. We want to talk about the music they liked and the jokes they used to make. We want to talk about precious memories and laughs we shared. But I’ve found it difficult to do so because over the years I’ve been met with discomfort and avoidance when I bring it up. I’m asking you, the reader, to help open up the conversation. By talking about them we can keep them as a part of our daily lives, even if they’re not physically with us anymore.

I’ll finish with a quote that someone shared with me when my Dad died. It means a great deal to me and it sums up my message wonderfully:

They say a man dies twice. Once when he stops breathing and the second, a bit later on, when somebody mentions his name for the last time.”

Author: Christopher Creene


Christopher grew up in Bristol, England, and moved to Canada when he was 15. He completed a BSc. in Microbiology & Immunology at Dalhousie University, and subsequently spent a year working at the QEII Health Sciences Centre as a phlebotomist. He is now on his way to completing his first year of medical school at Schulich. He is passionate about running, music, and the environment.

Photo Credits: Flikr, Creative Commons

How Medical Students Actually Feel About the Med Backpacks

Here’s a truth they don’t tell you when you get into medical school: you’ll be congratulated for it at least a hundred times. Your first congratulations will come from your official acceptance. Then you’ll be congratulated by your family, your friends, your doctor, your hairdresser, that chatty lady on the bus, professors during the first week of class, speakers from organizations vying for your money. But the Canadian Medical Association (CMA) will take it just one step further and give you their congratulations in the form of a brand new, brightly coloured, High Sierra backpack.

The backpacks aren’t subtle either; for those who know what they are, it’s an identifier. With every Canadian medical student in the same year having the same backpack, the wearer is visually inducted into a new group: medical student, class of ____.

There’s a sense of unity that comes from sharing an identifier with your class, and a sense of familiarity when you spot someone with the same backpack. In a way, the backpack is also a tribute to the hard work the wearer has put in to get into medical school. “Congratulations from us at CMA. You worked hard to get here, here’s a little something to let everyone else know that too.”

However, the backpack comes with responsibility. New expectations of professionalism and integrity are placed on medical students, even though we have yet to achieve ‘MD’ at the end of our names. The backpacks hold us accountable to the expectations of those who see us wearing it.

Or I could be wrong and it could just be a backpack. I asked some of my peers if they wore their CMA backpacks and how it might tie into their identities as medical students.

Mobolaji Adeolu, Class of 2021

I wear the CMA backpack because I find it valuable to be recognizable as a medical student. It allows me to identify and strike up conversations with other medical students at Schulich and throughout Canada. Moreover, I think it’s important for students from backgrounds that are underrepresented in medicine to be recognizable members of the medical community; both to show people striving for medical school that systematic barriers to admission can be overcome and to act as an approachable source of mentorship for students who want advice that can speak to their unique challenges.

Sarah Cassidy Howard, Class of 2022

I wear the backpack sometimes. I wear it when I have longer days because I have more stuff and it’s a really nice big bag that can carry a lot of stuff. On other days, it’s just nice to wear the backpack that I’ve always worn because it’s really nice, I’ve sewn patches in it, and it shows a little bit of my personality. So I feel like that’s nice to have as well—kind of a mix of both.

Bojana Radan, Class of 2021

I actually don’t wear my backpack. The first reason I always tell people is because my current backpack fits really well on my back, and I need to work on my posture. But secondly, I don’t like wearing it because I feel like I’m around medicine and medical school all the time in London, so it’s nice not being identified as solely a medical student outside of this space. Sometimes it’s nice to just walk around the city or go downtown where I don’t have to associate with that. I can just be that learner, be that person as a med student, but without actually showing it to the whole world.

I think it’s a great marketing advertisement for those that created it because it’s a backpack and its essential to students. I definitely think it [represents] that identity of the med school because it’s so hard to get in, so once you do get in—especially if it’s been your number one goal from the start—it’s kind of like wearing a badge of honour. So, I can definitely see that it plays into it, because other students know, and once … someone tells you it’s a med school backpack, you see it everywhere.

Jane Ding, Class of 2022

 

Initially, I wore my backpack to fit in, and I relied on the bright red backpacks to identify my classmates and find my way around a new school. I think that because of this, my world was narrowed down to Schulich and its students. It took time to realize that I was part of a greater community at Western. I think that as time goes on, I’m a little less comfortable wearing the bright red backpack that may set me apart. As medical students, we are part of the Western community. As doctors, identifying as part of the community we serve will be even more important.

Dan Li, Class of 2021

The first [reason I don’t wear my backpack] is that it’s really conspicuous. The moment you have that on campus, everyone knows who you are. And not just who you are, but roughly how old you are as well, because it shows your year (each year is different). The second reason is that it’s a little impractical. I’m not sure if you’ve weighed the backpack or not; it’s actually five or six pounds. I only usually take my notebook and my laptop with me, pens, my umbrella, and those things added together is like four pounds. So if the bag is heavier than what I carry around, it’s kind of pointless. And other than that, I just don’t like the look.

Katie Marriott, Class of 2021

 

I do wear the backpack, but I didn’t always. In undergrad I went to UBC and no other program had an identifier, only the meds. I wanted to be a medical student so badly and whenever I saw the backpack, it made me feel jealous and kind of angry. I felt like the students were flaunting it in my face—very negative things, looking back—which was totally on me. I shouldn’t have let it get to me that way. But nevertheless that’s how I felt. So at that time I vowed that if I were to get into medical school I would never wear the backpack. It’s actually quite dramatic I suppose, because of all the negative emotions that I thought that the backpack had given me. So for the first two months of first year, I did not wear it. I also started to notice some things that were a little bit unsettling to me, like when I would introduce myself to someone. They would ask me what I studied, and sometimes I wouldn’t say medicine. Sometimes I would say physiology or sciences, or just beat around the bush. I would sometimes have a bit of a stutter when I did say medicine, and there would be this horrible, awkward pause, “I study…medicine…”, which just made the whole thing quite awkward.” So from talking with some mentors, some [doctors] who had gone through it too, I came to see that the problem wasn’t the backpack, the problem was me now identifying (or not identifying) as a medical student. I had put so many stereotypes on that backpack and on medical school, a lot of them not good ones, and so I’d thought that by rejecting the backpack I could reject those stereotypes. I’ve since started wearing the backpack because I need to accept that this is who I am. This is what I want to study and I’m going to be a doctor. I can’t (and don’t want to) escape it, and I shouldn’t try to hide it anymore.

Wendy Wang, Class of 2022

 

I do wear my CMA backpack! Entering a new school with new goals in mind, it only makes sense to pair it with a brand new backpack. Functionally, it is large and sturdy, perfectly tailored to carry everything I need throughout the day. More importantly, the backpack symbolizes identity of medical students. The bright red backpacks of the class of 2022 fosters a sense of community, and with that, a sense of belonging. It is a comforting feeling to see a group of red backpacks on campus, knowing that they are my friends and my colleagues. Whereas it creates unity within medicine, the bright red colour of the backpack significantly stand out amongst a crowd. Wearing the backpack, therefore, holds me accountable to professional values, and serves as a visual reminder of the power and privilege I possess as a medical student.

Michele D’Agnillo, Class of 2022

 

Don’t wear the backpack, primarily because I like this backpack better. It’s smaller, and I like to separate my things, like have a lunch bag and a gym bag. And I like to scatter, like the lunch in the lounge or in the locker room. It’s kind of an aesthetic thing too. The backpack they give you is a little bit of a cheap one – I’m not a big fan of that. It may be subconscious, but it could have something to do with the fact that I may be a bit of a contrarian, I see myself as a black sheep, but I don’t think it consciously factors into the decision. Maybe a little bit.

 

Author: Nicole Lam

Nicole Lam graduated from Western University with a BMSc in Interdiscplinary Medical Sciences. She likes writing about science, pop culture, and student life. Nicole might be spotted on campus with a black, teal, or red backpack.

 

Photo Credits: CMA 

Do I Spend My Last Day Studying the Brachial Plexus?

January 25th

This is one of the many questions racing through my head as I walk through Victoria Hospital, tail between my legs and eyes at the floor. I’m approaching the Obs/Gyn call room after calling my boyfriend in tears for the millionth time this week while he tries to get his daily 6 hours before returning to night float. The bags under his eyes remind me that I’m the worst. I’m selfish, needy and lifeless. I’m not the person he fell in love with, I’m not the friend my classmates have relied on, I’m not the student that got into medical school. That person has been stolen with the body left behind.

I feel like I’m watching my life through a screen while an unidentified figure presses random buttons on the remote. The brightness has been turned down, colour desaturated with random alternations between fast forward and slow motion. The volume has been cranked so much that light vibration of emails, messages and schedule alerts and the inner mumblings of eating disorders past overwhelm my senses. Everything real that occurs around me is muffled and agitating. I’m begging them to press pause but they would rather taunt me with the OFF button, caveat being that there is no button to turn it back on. The OFF button has never looked so temping.

We are now laying in the call room which could also be used as an industrial sized fridge. I don’t cover need to cover up. My skin has numbed itself, so it can no longer feel the sweat of anxiety or the tears of depression. My stomach tied itself in a tight knot. My body is on standby – unwilling to fall asleep but never completely awake.

The exhaustion from this morning weighs me down like a ton of bricks. How many calories did I burn smiling and laughing in all the right places? I’m not cut out for this. One clinical methods session feels like I ran a marathon and I want to be a doctor. Good luck.

How did I get here? Last week I was bouncing around from study spot to the gym to the next exam feeling on top of the world. I may have gotten through an exam week without failing at least one, this was huge. I developed a foolproof plan to rock MSK and was pumped to spend a weekend in Blue Mountain with my class. I was going to clean up the apartment and leave some special treats to give my hardworking clerk the weekend to himself. Now the thought of leaving the apartment ties the knot in my stomach tighter and tighter. The thought of telling people I’m not going doubles it. Disappointing my boyfriend and impinging on his need for rest and solitude sends me into a tail spin. I have nowhere to go. Nobody deserves to put up with me right now.  I don’t want to put up with me right now.

There has already been three episodes like this since September. I’ve been dealing with mental illness since I was a kid. I always got tremendous satisfaction when doctors, counselors, whoever would ask “have you ever thought of hurting yourself” because the answer was always a definite no. Through the panic attacks, critical weights and depressive episodes, suicide was never an option I explored. It was empowering to think that even though my brain hates me, it wasn’t going to kill me. So now that these thoughts have popped up after 15 years, they are hitting me hard. Maybe they were by the 22 pounds I’ve gained since starting medical school. Maybe it’s the fact that I’m walking on eggshells around the UME due to my failed exams and missed mandatory sessions last year. Mental illness has finally gotten the best of me and I wasn’t strong enough to stop it. Imagine fighting a war for 15 years and losing. Imagine doing ground-breaking research for 15 years and having it thrown in the garbage and discredited. Would you want to start over?

What I should be doing is going to class and learning about this dreaded and deadly brachial plexus everyone is raving about. Hypothetically, if I was to take my own life, how pissed would I be if I spend my last days worrying about the brachial plexus?

January 27th

I am someone who wants to dedicate their life to caring for others and alleviating their pain and suffering. I believe that is he goal of most medical students. I feel tremendous guilt when I’m having suicidal thoughts because my mind always goes back to the patients. There are children diagnosed with terminal illnesses. We lose mothers, fathers and loved ones to cancer every day. These people did not deserve their fate and would do almost anything for another day. And here I am telling myself I care for these people while I take my life for granted. I wonder if the other physicians struggling with mental illness feel this way. I wonder if these thoughts contribute to the shame and secrecy that pushes us into a corner.

January 28th

My class should be getting back from Blue right about now. I’m dreading the explanations of why I ghosted everybody. Double dreading the explanations on why I don’t know the brachial plexus yet. As you can tell, I did not spend the last couple days studying the brachial plexus but I’m happy to report that it is not because these are my last days. I can feel the fog lifting and I’m not ready to give up yet. I realized I wasn’t ready when I spent two hours planning my clerkship rotations and talking about all the opportunities I have. My eyes are wider, my feet are faster, and my head is higher. Once I open this textbook to the brachial plexus in a couple minutes we will be 100% certain that I’m not going anywhere fast.

I could go back, cut out all my run-on sentences and edit this into a clean reflective piece but I’m choosing not to for three reasons. First, I think my chaos narrative is best reflected this way. Second, reading my thoughts and feelings from three days ago is petrifying. I barely remember that day, I can only remember the overwhelming sense of guilt and darkness. Third, and let’s be honest probably the most likely, is that I’m lazy and words are hard.

I also don’t know how to end this gracefully, so I’ll end it with some people I’d like to thank. The beauty of having a broken mind is that a somber reflection ends as an award acceptance speech.

To my mother, sisters, best friends and family: I am sorry I’ve been keeping this from 
you and not answering my phone.


To my niece: I could never leave you.


To my class: Even though I haven’t been open and honest with you guys please know 
that you are all the most welcoming and trustworthy people on the planet. I am 
in no way doubting your FIFE capabilities and I’m always here to FIFE you
right back.


To my favourite clerk and on-call superhero: I don’t know what I’d do without 
you these past months. Your confidence in my recovery makes me believe it’s 
possible. You are the love of my life.


To Learner Equity and Wellness and Schulich School of Medicine: You are doing a wonderful job. 
Thank you for caring about us.


And finally, to medical students and future colleagues: Be honest with each other, reach out 
when you need it. We got this.
If you or a friend is experiencing a mental health crisis, please contact 911 or visit your closest Emergency Department.
Visit Learner Equity and Wellness on-site or online for resources and support:
https://www.schulich.uwo.ca/learner-equity-wellness/learner_wellness/index.html

By: Cheyenne LaForme

Cheyenne LaForme is a second year medical student at Western University and the Local Officer of Indigenous Health.  She is using a portfolio-style reflection piece to raise awareness about, and cope with mental illness. She is originally from Hamilton and Mississauga’s of the New Credit First Nation and received a B.Sc. in Life Sciences at McMaster

 

Photo Credits: Creative Commons, Reaching

“Gaming” CaRMS: the game theory and history of resident matching

Let’s face it: the sight and sound of this term is a stress-inducer for many. This charming acronym stands for Canadian Resident Matching Service and match medical students with residency programs across Canada. Each year, the participating students wait anxiously for their results, and the non-participants wait anxiously for the match statistics.

The main concern usually relates to building a competitive application. However, lurking in the back of people’s mind is the mysterious CaRMS match algorithm. To address people’s curiosity (read: stress), CaRMS has a special webpage titled “De-mystifying the Match Algorithm” that contains key words such as “Roth-Peranson algorithm”, “rank order lists” and “applicant-proposing”. But how does it really work? For a better understanding of the mechanism and history of this “globally-recognized and award-winning” algorithm, let’s take a look across the border where the algorithm was first developed.

Medical internship in the United States was introduced in the 1900s as a form of post-graduate training. The idea gained popularity quickly for obvious reasons, but the implementation had a more troublesome history. Initially, medical students and hospitals made internship arrangements privately. An overabundance of internship positions relative to the size of graduating class each year resulted in a race among hospitals to recruit medical students as early as possible; some students received binding offers by the end of second year. Such a pre-emptive decision on the hospital’s side was risky and costly. Hospitals could potentially make a more well-informed choice if they withheld their offers until later, but they would then risk losing the brightest students to the early-acting hospitals. Consequently, everyone acts early –a classical case of Prisoner’s Dilemma.

The cost of this recruitment race was even higher for students. Many were still uncertain about their specialties of interest by the time they received an offer; signing a binding contract meant they might lose out on better options or make the wrong career decisions.

To mitigate the problem, medical schools established policies that prevented student information from being released to hospitals until a set date, forcing hospitals to make offers at the same time. This created a phenomenon of “exploding offers”. As hospitals scrambled to secure their preferred candidates, they shortened the response time for students to decide from 10 days to as short as 12 hours. Imagine if you were on a trans-Atlantic flight, you might miss your offer!

By the 1950s, it became clear that a central clearing house was urgently needed to facilitate the matching process. At first, a “priority matching” algorithm was proposed. Students and hospitals submit their preference lists for each other. In the first round of matching, those who put each other as first choices are matched and eliminated from the matching (1-1). Then, hospitals will be matched with their 2nd preferred candidates who rank the respective hospitals as first choices (2-1). In the third round, remaining students will match to their 2nd preferred hospitals who reciprocate by ranking the students as their first choice (1-2). The process goes on (2-2, 3-1, 3-2, 1-3, 2-3…). This proposal was rejected, as students would essentially be “penalized” for ranking hospitals they preferred but unlikely to secure.

Ultimately, a “deferred acceptance” algorithm was put forth. In brief, the proposing side makes offer to their most preferred candidates of the other party, who then temporarily accept the offer until they get a better deal in subsequent rounds – hence the “deferred” acceptance. Let’s demonstrate this in an example.

Assume there are four students who are trying to match to four hospitals. The students have a preference list, or “rank order list” (ROL), for the hospitals as shown:

 

Adam: Chrawna>Hammie>Vancity>Purple land

Beth: Chrawna>Purple land>Hammie>Vancity

Charlie: Vancity>Hammie>Purple land>Chrawna

Doug: Purple land>Hammie>Chrawna>Vancity

 

Similarly, hospitals rank the candidates as:

Chrawna: A>C>B>D

Hammie: B>C>D>A

Purple land: C>A>B>D

Vancity: D>B>A>C

Let’s start with the students as the proposing side. Adam and Beth both like Chrawna the best, so they both apply there. Charlie and Doug apply to Vancity and Purple land respectively. Now, since Chrawna receives two offers, it will be matched to its more preferred student Adam. Purple land and Vancity only receive one offer each and will be matched automatically. In this first stage of matching, Beth is unmatched. In stage two, she will apply to her second favourite place – Purple land. Even though Purple land is currently matched to Doug, it can still change its mind. After comparing its current match Doug to the new applicant Beth, the hospital selects Beth. At a result, Doug is now unmatched. Adam and Charlie remain matched to the hospitals from the previous stage. In the third stage, Doug will apply to the next location on his ROL, which is Hammie. Since Hammie still has not received any offer, it will happily take on Doug. Now everyone is matched and the matching process is complete.

 

Adam Beth Charlie Doug
Proposes to

Match

Chrawna

Chrawna

Chrawna

unmatched

Vancity

Vancity

Purple land

Purple land

Proposes to

Match

 

Chrawna

Purple land

Purple land

 

Vancity

 

unmatched

Proposes to

Match

 

Chrawna

 

Purple land

 

Vancity

Hammie

Hammie

Final result Chrawna Purple land Vancity Hammie

 

As a result, Adam is matched to Chrawna, Beth to Purple land, Charlie to Vancity, and Doug to Hammie.

On a cautionary note, in practice, students do not actually have to propose to hospitals repeatedly. Instead, these “stages” of matching are simulated – presumably with powerful computers at National Matching Services Inc. – with only one round of ROL submission to the central clearing house. In the context of CaRMS, each submission of ROL is equivalent to one round of iteration.

One may then wonder: does it matter which side starts the process? In the example above, the students make the “proposal” first. If one starts the process with the hospital side, there will be only one round of matching. The results are: Chrawna with Adam, Hammie with Beth, Purple land with Charlie, and Vancity with Doug. Every hospital will get their first choice, but the students will be worse off with their less preferred hospitals (just compare the results according to the students’ preferences). In general, student-proposing will lead to better or at least equally good results for students, since they essentially get their picks before the hospitals.

Is there a way to “game” the system? The simple answer is, not really. There is no incentive to put your “safer” options higher on your list just so that you are matched to at least somewhere, because you may potentially miss out on better matches. There is also technically no penalty for putting your “dream” hospital as your first choice. Even if you are rejected during the first “stage” within a submission, you can still “propose” to your other options and be accepted in later stages. As a result, the Deferred Acceptance algorithm elicits “true” preferences: students have no incentive to submit a rank order list that does not reflect their wishes.

In addition to solving the recruitment race, exploding offers, and too-risky-to-dream-big problems, this algorithm also produces so-called “stable” matches. Going back to our example, there is no pair of hospital-student such that they prefer each other to their assigned partners. Even though Hammie prefers Beth to its current match, Beth is not willing to give up Purple land for Hammie.

There have been modifications over the years to incorporate match variations such as couples matching. Nevertheless, “deferred acceptance” concept remains central to the currently used Roth-Peranson algorithm. It is used for resident matching in both US and Canada. If this post has not been re-assuring enough, the algorithm was also pivotal to Roth winning a Nobel Prize for Economics in 2012 – a truly “globally recognized and award winning” match program. Indeed, not many matchmaking solutions can be quite a match for this one and its making.

 

Resources:

De-mystifying the Match Algorithm http://www.carms.ca/en/about/blog/de-mystifying-match-algorithm/

The Match Algorithm http://www.carms.ca/en/residency/match-algorithm/

Alvin Roth “The Origins, History, and Design of the Resident Match”

Alvin Roth and Elliot Peranson “The Redesign of the Matching Market for American Physicians: Some Engineering Aspects of Economic Design.”

 

10 Tips on Choosing a Specialty

In undergrad, you’ve spent countless hours studying for exams, perfecting your immaculate GPA, and preparing for the MCAT – to become the ideal candidate for medical school. Now that you are medical students – congratulations! – you are studying to become the best doctors. But what type of doctor do you want to be?

Some of you already know the answer before entering medical school. You may have heard your friends say “I’ve always wanted to be a cardiologist”, or “I was born to do neurosurgery”, or “I came to medical school to become a family physician to serve my community”. But no matter if you are set on a career path, or are undecided, keeping an open mind is perhaps the most important. Through personal experience in medical school, I’ve compiled the following 10 tips on choosing a specialty:

1. Keep an open mind, as discussed above. This is a point worth emphasizing. About half of my friends changed their specialty of interest through the course of medical school. A few announced a new interest at the end of each inspirational block.

2. Explore each specialty that interests you. For example, do an observership, take a summer non-credit elective, or participate in research (SRTP, SROP, SWORP)… But if you do not find an opportunity to do so, there is still Year 3 Clerkship where you will rotate through the major areas of medicine.

3. Ask yourself, what do you like about this specialty? You might have seen an exciting procedure such as stent-deployment in the cardiac cath lab, or enjoy talking to people about their struggle with depression and mania, or gain satisfaction by identifying features of nuclear atypia on a pathology slide that lead to the diagnosis.

4. On the other hand, what are the undesirable aspects of the specialty? For example, will you still be happy, at the age of 50, to be paged at 3 am for an emergency appendectomy? Will you be bored of titrating furosemide in the heart failure clinic? On the contrary, some people find these aspects of their job the most rewarding.

5. Will you enjoy the “bread and butter” work of this specialty, and not just the rare and exciting cases? After all, you will be doing this job every day for rest of your medical career. While it’s theoretically possible to “see the light” and change your specialty mid-career; it is generally not advised.

6. If you are unsure, use the process of categorization and elimination. Some common contrasting themes are: Generalist vs. specialist. Primary care vs. consultant. Doctor’s office vs. hospital care. Medicine vs. Surgery. Procedural vs. non-procedural. Adult medicine vs. Pediatrics. etc. Here is an algorithm from the BMJ.

7. If you are still undecided, like many students, then reflect on what fits your personality. Some people prefer working with their hands such as in orthopedic surgery, while others enjoy contemplating complex concepts such as hormonal pathways in endocrinology. Each year, the Learner Equity and Wellness (LEW) Office offers the Myers-Briggs personality test that may help you determine a suitable specialty.

8. Sometimes there are more than 1 path to becoming the doctor you want to be. For example, the family medicine 2 + 1 residency program is an attractive but competitive career path. For example, you can do 2 years of family medicine + 1 year emergency medicine, obstetrics, or anesthesia, to name a few.

9. If you are torn between 2 (or more) specialties and it’s almost 4th year, some students split their elective time in both subjects. Others choose multidisciplinary electives, such as ICU which involves internal medicine, anesthesia, and surgical critical care. But it’s riskier to match into a competitive specialty, that may sense your ambivalence.

10. Although it’s never too late to decide on a specialty, ideally you want to make a decision before applying for 4th year electives, and at the latest before the CaRMS residency match. Never be afraid to seek help. Talk to your peers, upper year students and residents, or make an appointment at the LEW Office, if you would like more guidance.

Choosing a specialty is a career-defining decision. You came to medical school from diverse backgrounds, for a variety of reasons, to become a doctor. I hope that you will soon find the specialty that suits your calling! This blog post covers the main points, but is by no means an exhaustive list. To the upper year students, if you have other considerations that helped you choose a specialty, please feel free to comment below! To the junior students, you will be surprised at how quickly medical school passes, despite the lengthy lectures, mountain of notes, and seemingly endless exams. So may the wind be behind your sails as you set off on a voyage of discovery in the vast ocean of medicine!

Pei Jun Zhao

Meds 2017