PGY-2 Internal Medicine – University of Toronto
My name is Anthony Lott and I am a PGY-2 in internal medicine at the University of Toronto.
I was born and raised in Edmonton, Alberta. I attended the University of Alberta for medical school as well as my bachelor of science in physiology. I moved to Toronto to complete a residency in internal medicine.
I encountered several excellent and influential mentors during my clinical clerkship who swayed me towards a career in internal medicine. Working with many talented internists, I was always impressed by their depth of knowledge, their broad approach to any problem, their thoroughness, and most of all, their compassion and empathy. While internists manage a broad variety of clinical conditions, my most memorable interactions have been with cancer patients and their families. Drawing upon my interest in basic science oncology, as well as the impact that cancer has had on my own family, I am positioning myself toward a career in medical oncology via internal medicine.
What does a typical day of clinical duties involve?
Internal medicine residents spend almost their entire residency completing “on-service” rotations. In Toronto, five months of PGY-1 are spent on the CTUs with the remaining eight blocks distributed among the various subspecialties.
What kinds of clinical rotations are required in your program?
The Royal College Objectives of Training specify that internal medicine specialists become trained in the treatment of a broad range of diseases in adults involving all organs and multiple organ systems. To achieve this, clinical rotations largely occur within the inpatient hospital setting; however, there are additional outpatient ambulatory components to some subspecialties (e.g., rheumatology, endocrinology). At Toronto, internal medicine residents rotate through all the major internal medicine subspecialties, with limited time on off-service rotations (neurology and emergency medicine). A majority of time is spent on the CTUs in PGY-1, with a shift towards critical care rotations in PGY-2 and medical consults in PGY-3.
Which of your personality characteristics have been particularly helpful in your field?
Communication skills are really important. Our patients range from being healthy and well compensated in the outpatient setting to being extremely sick and on the brink of death in the ICU. As we are constantly talking with patients and families, internists require strong interpersonal skills and excellent communication skills. Being a patient and active listener is especially critical when working with complex and often elderly patients who are admitted to the hospital.
It also helps to be diligent, thorough, and inquisitive. Internal medicine is a highly detail-oriented specialty that values critical thinking, problem solving, and comprehensiveness. Internists are constantly asking questions to develop an understanding of a patient’s disease. Being focused on details and having an inquisitive mind helps to challenge assumptions and ensure accurate diagnosis and management.
What are the best aspects of your residency?
There is amazing pathophysiology within the field of internal medicine. We revel in the weird and wonderful diagnoses that you will only encounter in textbooks, and we are fortunate to see such diverse and fascinating cases. Truthfully though, the best part of my residency is working with my fellow dedicated residents, nurses, and allied health staff who are committed to the well-being of complex, frail, and often marginalized patients.
What are the most challenging aspects of your residency?
As our aging population swells and their medical issues accumulate, the hospital faces invariable pressure to admit increasing numbers of acutely sick and decompensated patients. From the internal medicine resident’s perspective, this translates into high patient volumes, high workload, and the need to juggle multiple tasks and patients. While we don’t work the hours of surgeons, taking call on CTU can be exhausting, both mentally and physically. Medicine can also be emotionally taxing, as we often deal with complex patient dynamics, critically ill patients, and death.
What is one question you’re often asked about your residency?
Medical students often ask me how I am able to tackle all the knowledge required to be an internal medicine specialist. The breadth of internal medicine is daunting, but I believe that knowledge comes with time and experience; it is more important to recognize what one doesn’t know and learn how to look it up. Much of our learning in internal medicine comes through doing; sitting down with a textbook or reading through UptoDate is a luxury that I don’t always have time for. A lot of medical knowledge is picked up from repetition, as we get asked the same questions over and over. It also helps to have a great phone app for eponyms!
Can you describe the transition from clerkship into residency?
The transition from senior medical student to resident on July 1 can be daunting and frightening. While there are always extra measures in place to ensure patient safety during the first month of residency, it takes time for residents to adjust to their new expectations and responsibilities. My words of advice: 1) Help is always available from senior residents all the way up to attending staff; you will never be faulted if you take extra time to run a case by somebody more senior in the interest of patient safety; and 2) Mistakes are a natural part of the learning process; be conservative when you are uncertain, and be assured that there are multiple failsafe mechanisms within the hospital to prevent harm.
What are your future practice plans?
There is so much variety in internal medicine that it is often difficult to choose a specialization. There is a trend toward generalism among internal medicine specialists, and a variety of patient settings are recruiting for general internists. Halfway through my core training, I have narrowed my focus to medical oncology, likely within an academic setting, though I would be open to practising as a general internist in the community if my career plans change. Some internal medicine career options are becoming more limited as hospital budgets are constrained for resources such as endoscopy suites and catheterization labs. Given my ambitions, I am prepared to take additional fellowship and masters training, and have opened the door to train and work in the United States by completing my USMLEs.
What are your fellow residents like and how do you interact with each other?
Some of my colleagues are very laid-back and relaxed; others are go-getters who can sometimes be quite intense. Internal medicine being the largest program in Canada, I would say my fellow residents run the gamut of personalities, but commonly they are friendly, personable, collegial, and very smart. Though we have a few international residents who have come to Canada with their families, I believe my cohort is relatively young and a majority are at an early stage of their personal and family lives.
What are your academic interests (e.g. leadership activities, research)?
I have always enjoyed participating in administration and took on many leadership roles throughout medical school. This has continued in residency through my roles with the Professional Association of Residents of Ontario (PARO) as well as our national organization, RDoC. I also enjoy teaching medical students in the University of Toronto’s Clinical Skills Program: The Art and Science of Medicine (ASCM).
The research program at the University of Toronto is a huge strength of our internal medicine program, and I have taken on projects in quality improvement and clinical oncology. Many residents take research blocks in Toronto; this has given me protected time to focus on scholarship.
What is your work-life balance like, and how do you achieve this?
Moving to Canada’s largest city was a change that I am still adapting to, but I am lucky to have a good network of friends who are working or pursuing residency training here. I took up running half marathons in medical school and I have continued this as a resident. I also head to the gym on a regular basis for strength training. Apart from physical activity, I joined a community choir and have been trying to take up cooking. The food scene in Toronto is unparalleled so I often find myself venturing to new restaurants in the city.
With regard to balance, it is true that when we are on service for CTU, ICU, or CCU, the days can be long and laborious and the nights are often sleepless. But the converse, which students don’t see, is the down time when we work in the outpatient setting, on quieter inpatient consult services, or on research. Maintaining balance is a constant challenge, especially when having free time can be infrequent. For me, it comes down to prioritizing personal wellness, trying to maintain an active life outside medicine, and recognizing when I need to take a break from work. Scheduling vacations is important, and I try to take a two-week international voyage with my family every year.