I wanted to write about dissatisfaction and doubts that students have with respect to medical school, and the factors that culminate in students leaving the program.

And, although it might seem a suspiciously timely topic, given that I just finished the toughest set of exams we've encountered these past two years, I assure you it's simply a coincidence. My exams went well, and now I'm getting some rest and tackling a list of errands a mile long...

Once they've gotten in, very few people actually leave medical school. In some ways that's surprising: You might think that with such a rigorous program, you'd have more people who decide they either can't or no longer want to continue. On the other hand, it isn't terribly shocking that most of us get through it: We are carefully selected to make sure that we have the ability and drive to succeed. That's important because training a physician costs governments (and ultimately taxpayers) quite a lot of money.

The darker side of why people might not drop out is that by the time they realize they don't want to be physicians, they might be in so much debt that leaving the program might not be an option. We pay roughly $17,000 a year in tuition; if you add living expenses to that, after two years you're in roughly $60,000-70,000 of debt. Keep in mind, that's not counting debt from an undergraduate degree. Taken together, it's a lot to pay off without a physician's salary, whether someone plans on working or going into another professional program.

Some students are also under pressure from their families to succeed.  Whether it's because their parents, grandparents, aunts and uncles are all doctors or because they're the first in their families to venture into the medical profession, the impact is the same: They feel a duty to complete the program and fulfill certain expectations. Medical students are also a fairly stubborn bunch who see themselves as being pretty resilient; they don't like to think of themselves as being "quitters," even if leaving medical school would be the best decision long-term.

The research around this has found that in the United States, roughly 3 per cent of medical students don't make it to graduation. A large study at multiple medical schools found that 11 per cent of medical students had seriously considered dropping out within the last year. Those who had considered dropping out were more likely to score low on quality-of-life scales, report more symptoms related to depression, be suffering from burnout, have children, and to have experienced a major negative life event.

Someone I chatted with who was seriously considering dropping out told me that he simply didn't realize the impact that medical school would have on his life. Before starting the program, he had an interesting job with a reasonably good salary, and got evenings and weekends off to pursue a multitude of hobbies and spend time with friends and family. As his extensive non-medical social network continued to go on weekend trips and spend time relaxing, he was constantly turning down their invitations in favour of class and study groups. Over time, he became more and more disillusioned. While he understood that a medical degree meant a great deal of sacrifice, he wondered whether the sacrifice of his twenties was worth the payout of meaningful work and a better salary in his thirties, especially since he thought he might be happy doing something that didn't require so much schooling.

A couple of things kept him hanging on. He turned to the Internet, where he found dozens of people like him who were also seriously considering leaving medical school. He very quickly realized that many of them had tangible exit strategies and had laid careful plans, while he only had vague notions of finding another job when he got out. He also got more involved with some work that put him in direct contact with patients. Although this took up a significant amount of his time, it helped give all of the hours he was spending in the library some meaning and motivated him to work even harder, since he felt a sense of responsibility to know the material he was learning so that he could better serve his patients.

He touches on an important point. What drives most of us, I think, is a desire to work with patients, develop relationships, and use our knowledge to improve their health and ultimately their lives. But it can be really hard to see the light at the end of the tunnel when we're spending days on end trying to review and retain material and thinking, "Why won't things just stick? Why do I keep forgetting things I learned, like, yesterday?!"

A person who chose to leave a Canadian medical program offered this wise advice: "Don't expect to be able to do everything in med school." 

He went in - and he made this clear during the application process - with the intention of being more than "just a medical student." He had spent years successfully doing research and advocacy work that he didn't intend on simply giving up when he started the program. He was ready to scale back, but wasn't willing to give up what was up until now his life's work.

He cautions those considering applying to "apply with the expectation that they will have to largely [read: entirely] give up spending much time with things outside of school while in medicine."

In the course of making his decision, he spoke with various people both inside and outside the field. He realized that medical schools seek out applicants who are well-rounded, ambitious, and successful at what they do, and use that as a proxy for future success. So they recruit people who have started national charities, done ground-breaking research, competed in the Olympics ... then ask them to quit all that and mostly focus on medicine.  And that's where some of the problems start.

While he is disappointed that he is not able to continue in a field he is passionate about, he admits, "I don't know if there is a better system." He says that medicine is a demanding field, and that we want to continue to recruit motivated and hard-working people who will pour their energies into being great physicians. Otherwise, we're risking the lives of patients.

I've certainly experienced dissatisfaction over the last two years; I can't imagine a medical student who could claim they haven't. At points I've been unhappy with the way some topics are taught and with my own performance. But I think the important point is that, all things considered, my overall experience has been a positive and reinforcing one; the effort I've put in has been rewarded and I enjoy what I'm learning, and that's likely true for a lot of my classmates.

None of this is easy. Figuring out whether a career is right for you comes down to understanding what you're passionate about, what amount of work you are realistically able to do to get there, and how that commitment fits into your current life and your future goals. While it's not always so simple and formulaic, it's a start.

Every year in May, medical school hopefuls from across the country wait anxiously at their mailboxes (those still exist!) and inboxes waiting to hear back from the institutions they've applied to. They're eager to know whether they've been accepted, outright rejected, or put on the waitlist, in which case they will spend their summers in acceptance limbo, hoping against hope that someone will decide to take a year off or accept a spot at another school, so that a place will open up for them.

It's a tough process for most, and it's not uncommon to have to apply twice or even three times before being accepted. The difficulty inherent in the process invariably leads to a lot of soul searching: Am I wasting my time? If I don't get in, do I apply again or do I move on to something else? What on Earth am I going to do with my life if this doesn't work out?

When the answer to the long-awaited question is ultimately no, those vying to get in - as much as it may not feel like it at the time - have options.

Some choose to pursue a master's or PhD, that is if serial T-tests, mice, and lab meetings turn them on. They can always try their luck at getting in once they have finished their graduate degrees, or they can choose to work and spare themselves from (more) debt and sleep deprivation. The belief among students is that a graduate degree can make you a more competitive applicant, and that you get more 'points' during the ranking process if you've got one.

Many decide to work and volunteer while re-applying.  This can feel like a better option because while in the middle of your graduate degree, you can't apply to medical school. You can only apply during your last year, and you have to actually finish the program (which includes writing that thesis thing) before you are allowed in. A lot of pre-meds do research in areas like public health, biochemistry and infectious disease, but others work with non-governmental organizations or as professionals (we've got lots of teachers, engineers, nurses in my class).

Others apply to medical school abroad.  This can be a fairly costly option since medical schools in Ireland, Australia, and the Caribbean that cater to international students tend to cost several thousand dollars more per year than Canadian medical schools. One must factor in the issue of trying to secure either a residency or a position post-residency in Canada, which is considerably more difficult when you're an "international medical graduate."

Some travel the world while trying their luck again, a good option as far as I'm concerned because you get so few opportunities to do that kind of thing while in school. Might as well see the world while you have the time, and while you're not doing it with your line of credit (which should technically be for "school and living" expenses, though that definition certainly gets distorted along the way).

A final subset of people decide to forget it and do something else completely, and go on to live perfectly happy lives free of call schedules and risk of needle sticks.

I applied twice; the first time, my interview wasn't the best ... and that's putting it gently.  I was nervous, nervous, nervous. I couldn't sleep for the 5 nights before my interview, stumbled on my words, and doubt I impressed too many interviewers. That year, I was waitlisted - not to mention devastated - and eventually dropped from the waitlist sometime in August, which made for a harrowing few months. I wish schools could let applicants know earlier than May, so they don't spend some of the most gorgeous months of the year moping and feeling sorry for themselves.

I worked in research while I re-applied, this time more determined and with a stronger application. I prepared for my interview months in advance, did some yoga in the weeks before my interview, crossed my fingers for good references, and was eventually accepted.

But had I not gotten in that second time, I think it would have been incredibly difficult to re-apply. The process takes a huge toll on your self esteem, and the people around you, as supportive as they try to be, don't always make it easier: to hear that they "believe in you" and that "you're meant to be a doctor" doesn't make it any easier when you don't get in. Their support can make you feel like you're letting them down, which is hard enough because you're already beating yourself up because you've let you down.

I think that a lot of people are tempted to give up, say it "isn't what I really wanted to do," and find another career path. Fair enough.

But I'm glad I hung on through that second application process.  The reality is that it gave me a good sense of what being in medical school is like: your ego takes a hit on a near-daily basis, and you have to constantly remind yourself exactly why you're putting yourself through 30-40 hours of class every week and dedicating most of your free time to studying. Through that second application process I realized just how much I really wanted to get in. Whenever I'm sick of studying I remind myself that I wouldn't want to be doing anything else, and not only do I want to be a doctor, I want to be a good one, so there's really no time to be "sick of studying."

                And then I go back to the books.

I'll be writing a number of posts about rural health care, which will coincide with the first part of my third year clerkship, where I will practise with a family physician in a rural area in B.C. for four weeks.

There has been a great deal of buzz recently about an initiative to spend $39.5-million of federal money to fund the creation of new residency positions across the country aimed at training more rural physicians. With the election pending, campaign promises include an NDP plan to forgive student loans for medical workers who practice in rural areas for 10 years or more. This got me thinking about the rural physician shortage and some of the measures being taken to alleviate the problem.

The shortage of physicians in rural areas is actually a global one, not just one we face here in Canada: it seems no matter where you go in the world, rural and remote places don't have as many physicians as urban ones do.

The issue also applies more to family physicians than anyone else. Now, I imagine you're probably wondering, "Don't rural areas need cardiologists, surgeons, and anesthesiologists just as much as they need family physicians? They get heart attacks/need gallbladders removed/need to be put under, too!"

While it's true that people experience similar medical problems and need more or less the same kind of care in both rural and urban areas, the problem is this: working in a town of a 1,000 people, anesthesiologists, cardiologists or surgeons are unlikely to have a patient base large enough to support their practice. Nor are they going to be as in-demand as family physicians, who can diagnose heart problems, examine gallbladders and get patients flown to larger hospitals to be operated on, and get trained in anesthesiology so they can anesthetize patients if there isn't anyone else around to do it.

According to the Society of Rural Physicians of Canada, "with sub specialists and high technology of large cities distant, country doctors work in small groups in settings which require a broad spectrum of clinical skills." This broad spectrum of clinical skills allows them to diagnose and treat most of what comes through the door, which is why government incentives tend to be aimed at family physicians.

Federal and provincial governments have been working for years to create incentives to encourage physicians to practice in rural areas. Some of these include:

-   Student debt relief for those who practice in a rural area for a defined period of time after graduation

-    Encouraging/mandating that international medical graduates (called 'IMGs') practice in rural areas for x number of years after they finish the training required to practise in Canada.

-    Expanding medical schools to rural sites, in an effort to enhance the profile of the medical school to students in rural areas and to encourage them to apply, but also to train urban students who may have an interest in rural medicine in these areas, in hopes that they'll settle and practise there after graduation.

These initiatives are a testament to how seriously governments and medical schools are working to address the problem. Rest assured that for a medical school it's no small feat to have your students distributed over two, three, or even four different sites, potentially hundreds of kilometres apart. UBC's medical school is distributed across three different campuses (Vancouver, Victoria, and Prince George) with one in Kelowna welcoming students in January 2012. It truly takes a small army of administrative and IT staff to ensure that we receive the same quality training no matter where we are in the province. They ensure that our classes run on time, that lectures get broadcasted to the various sites, that we can communicate quickly and effectively with each other during live sessions (all our classrooms are equipped with dozens of video cameras and microphones), and that there are enough doctors to teach us one-on-one when we work with patients.

UBC's not the only one: Across Canada, rural programs are popping up as "satellite campuses" of a number of medical schools. The Northern Ontario School of Medicine has main campuses in Thunder Bay and Sudbury, with multiple teaching sites distributed across Northern Ontario. Memorial University's Family Medicine residency program has another site in Goose Bay, Labrador, allowing residents the option to do a considerable chunk of their training up North.

While medical education itself tends to be expensive, rural medical education is even more expensive. With substantial resources being dedicated to training medical students in rural areas in hopes that they will eventually elect to live and practise rurally, I think our biggest concern (as taxpayers, as patients, and as people concerned about access to health care in rural communities) should be whether these measures are working.

If the intention of creating a medical program in a more rural area is to train physicians who will stay in that area, I think medical schools need to be very, very careful whom they admit into those rural programs.

Simply put, medical schools in Canada tend to get hundreds, often thousands more applicants than they can accept and competition is fierce. There are individuals who will try to get into medical school anywhere they can get accepted, and potentially feign interest in rural medicine if it means that they get accepted to a rural training site. The education is still top notch, and so what if they have to 'suffer' through a few years far away from friends, family, and urban perks?  They'll do it, but they're not likely to stay after they graduate.

I think that medical schools need to work as hard as possible to recruit students from rural areas into rural medical programs. It makes sense: If you grow up somewhere, and your friends, family, and all the wonderful things that make a place "home" to you are there, you'll likely want to stay there or return once you've completed your training.

This is also a consistent finding from the research: Students from rural areas are more likely to practise rural medicine.

Given these findings, you would think that it would also make sense to increase the number of medical school spots available to students who have grown up rurally. But there's a problem: Rural students just aren't applying.

There are many reasons why: Rural high schools have diminished access to academic resources, and allow fewer school subject choices. Rural high-school students also lack the same access to academic and extracurricular activities as urban students, as well as easy access to colleges and universities close by.

Compare this to my urban experience. There were high schools within a 12-minute drive where I could take advanced-placement courses and International Baccalaureate classes (I didn't, but that's not the point...), there were dozens of volunteer and extracurricular activities at my disposal, and I was within a 35-minute drive and 1-hour bus ride of two major universities and a half dozen colleges.

With all of these ideas, resources, and opportunities at my disposal, I started forming plans. At one point during senior year, my closest friend in high school and I planned out our whole post-secondary education experience. We would pursue degrees in biochemistry, go on exchange to exotic places, and then attend McGill medical school (because we'd want to practice our Français and who doesn't love Montreal?).

None of that actually happened, but it doesn't matter: The seed was planted and the opportunities were there, which I seized.

I think we need to work to plant seeds and create opportunities for rural students at an early point in their education if we expect them to apply and be accepted to the rural medical programs that we have created with them in mind.

I'll be profiling some of the initiatives aimed at doing this in a few months, so stay tuned.

More than 90 per cent of Canadians say that a family physician is the first person they would turn to in order to address their medical problems. Research also shows vastly improved population health outcomes in communities with better access to family physicians, where an additional family physician per 10,000 people is associated with a 5.3-per-cent reduction in mortality.

Sounds great, right? Family doctors are highly valued by the public and seem to work wonders from a population health perspective. Unfortunately, in 2004 it was reported that roughly four million Canadians couldn't find a family physician. And the reality is that at some medical schools, family medicine takes the backburner when compared to some of the "sexier" specialities, such as ophthalmology, surgery, and internal medicine.

A few months ago, I attended a family medicine conference aimed at medical students. It showcased the many rewards of a career in family medicine and the diverse array of opportunities family physicians have after they graduate. What I came out with was some insight into what makes family medicine an appealing career. What I learned went against what some students believe to be true of the field: that you have very little variety in your work (meaning you only deal with coughs, colds, and high blood pressure) and that you make very little money doing it.

One major theme to come up was the idea of blended practices, where we're seeing more and more family physicians designing their schedules to include varied work. Traditionally, most family physicians have worked full-time seeing patients and have dealt with everything from heart disease to skin cancer and obstetrical care.

These days, we're seeing family physicians who might still see a variety of patients and problems, but cut down on clinic hours in order to accommodate research and other professional interests. One presenter discussed his work with a particularly challenging group of injection drug users in Vancouver's Downtown East Side. In order to ensure that he doesn't suffer from burnout, he practices roughly three days a week and spends the rest of his time doing addictions research.

I thought this was an interesting idea that might work for me: I'm attracted to the field of geriatric medicine but it's not something I want to do full-time. A family practice combined with one to two days a week of work in an assisted care facility might be a nice middle ground.

Next came the idea that these days, family physicians  are actually bringing home a fairly decent income. Now, I'll be the first to admit that, compared with the general public, physicians on the whole make very acceptable wages; however, within the field there are vast differences in how doctors get paid, and from what I can tell, it leads to some disgruntlement among physicians.

From the student perspective, ophthalmologists tend to be at the top of the pay hierarchy (so it shouldn't be surprising that it's one of the most fiercely competitive specialties to get into); surgeons, dermatologists, and radiologists hover just below, then come internists, with psychiatrists and family physicians near the bottom of the totem pole.

But, as one of our speakers emphasized, this doesn't need to be the case. She described how some family physicians are working 50-hour weeks and coming home with (in relative terms) next to nothing. But, in her experience, these physicians are more often than not "leaving money on the table". These are physicians who receive no training in medical school or residency around managing a business, and suddenly become owners of their own practices and in charge of day-to-day operations. Because they're not the savviest business people in the world, they bring home less money than they should, which leaves them tired, fed up, and wishing they'd had more of an interest in glaucoma and cataract surgery back in medical school.  To help remedy the problem, she works with these family doctors to ensure they get paid appropriately for their work.

The last interesting theme to come out of the conference  was the notion that, as a family physician, you can do additional training to enhance your skills, pursue a more focused area of interest, and better serve the medical needs of your community. The best example of this is the one-year training program that allows family physicians to train in the area of emergency medicine (which sets you up to work in hospital emergency departments). The program was developed with rural areas in mind, since often rural hospitals are staffed chiefly by family doctors (unlike larger urban hospitals, which tend to be specialist territory).

What's interesting is that, if there isn't a formal training program set up for you, in some provinces you can even create one, as one of our speakers did after she finished her training and realized she wanted to work exclusively in the area of women's health.

While it's hard to know in your second year of medical school what you "want to be when you grow up," I'm becoming progressively more interested in generalism, or fields where you work with a large variety of patients and problems. And a career as a family doctor looks like it fits very well into that, but it's hard to know, not having been exposed to other fields, such as emergency medicine and internal medicine. In a lot of ways, that's what your third year is for: As you rotate through different specialties and actually manage and treat patients (with supervision, of course) you get a better sense for what you're good at, what you enjoy, and what you could see yourself doing ... when you're all grown up.