[MMI prompt] Non-paternity

You are a genetic counselor.  One of  your clients, Linda, had a boy with a genetic defect that may have a high recurrence risk, meaning her subsequent pregnancies has a high chance of being affected by the same defect. You offered genetic testing of Linda, her husband, and their son to find out  more about their disease, to which everyone agreed. The result showed that neither Linda nor her husband carry the mutation, while the boy inherited the mutation on a paternal chromosome that did not come from Linda's husband. In other words, the boy's biological father is someone else, who is unaware that he carries the mutation.

You suspect that Linda nor her husband are aware of this non-paternity. How would you disclose the results of this genetic analysis to Linda and her family? What principles and who do you have to take into consideration in this case?

[MMI prompt] Health care

In a particular socialist society, the health care system is set up as follows: the public shares the cost of health care, and everyone who needs it enters a line-up. Because the public funding is limited, the health care system does not operate to its full capacity (in other words, some doctors want to work more hours but can't get paid for extra hours), and the line up for health care is long.

It has been proposed that in order to reduce the burden on health care, we allow some patients to pay for their medical services and receive them faster. It is argued that the rest of the public will not have to wait any longer, because the doctors and surgeons have unused hours, and the private funding goes to pay for these hours instead of jumping the public line.

Discuss the pros and cons of the introduction of this two-tier system (ie. coexisting public and private funding sources for health care).

[MMI prompt] Doctor's obligation

You are an ER resident who specializes in trauma. One day, a martial arts sportsman is sent to your ER with an apparently throat injury. His coach said he was hit by the opponent in the throat during the semi-finals match. You are aware that in this type of martial arts, attacking unprotected areas of the head such as the throat is ground for disqualification.

Your attending physician (your boss in the hospital) told you that the opponent of the injured player is your countryman, whereas the injured player is a foreign contender of the champion title that your country values highly. He wants you to "examine the injury carefully" right after he remarks how important the match is for the country.

How would you handle this situation?

[MMI prompt] time management

You are a cardiologist at a local hospital, who just finished a shift and has a tight run to your daughter's high school graduation ceremony. As you headed off to the door, Mark, a patient who knew you well, saw you from the waiting room and grabbed your attention. "Doctor! I have a bad chest pain. Please stay for a bit. I'll feel much better if you were here."

Enter the waiting room and talk to Mark.

[MMI prompt] driving a friend

Prelude

I'm sure if you have googled "practice mmi" or anything to that effect, you would have come across a very good set of 10 practice questions, with a variety of categories. If you haven't already, practice with these first. This set of questions are prepared by people who created the whole MMI business, and few things other than doing a real MMI can give you a better pictures than this.

Having said that, it'll be quite easy to finish all of these questions and still feel under-prepared. That's why I'll post some questions that I've come up with (in no shape or form are these from my real MMI for obvious reasons), as something you could think about as you prepare.

Driving a friend

You have been in a new relationship for 5 months, and you just got into medical school. As the saying goes, many relationships are ended in med school because of the stress, and lack of time, and the excitement of meeting hundreds of new, young,  intelligent soon-to-be doctors. You suspect that your partner is slightly worried about your attending medical school.

One evening, you have to attend a social event that your partner cannot go to. One of your colleagues from out of province asks you for a ride to the party, as he/she does not know how to get there. You feel slightly uncomfortable but at the same time obligated to help as a local and a friend.

How would you approach this situation?

[Interview] 5 days till the Big Day

I went to the Wine and Cheese social event organized by the Med Undergrad Society last weekend, and it was really a wonderful night (for various reasons :P). Social-wise, I got to know more med students and reconfirmed my finding that these people are the coolest kids in town. They are so dynamic, so unique, and all so enthusiastic about what they do... I want to be a part of this family.

A few interviewee friends of mine were there too, and one of them were quite nervous about her upcoming interview. She has it at the same timeslot as me.

I, on the other hand, was totally chilled. I could think of a few reasons for this too:

1. I've approached this application as a test run -- just to test the water and see how things work. My real med school application effort will come next year.

2. I'm never the type that gets nervous about exams and interviews; I was talking to another friend the other day, and I figured that my mentality is "do all I can do and see what happens".

3. My mind is just too damn occupied right now to worry about med interview. Is there anything more important than an imminent interview? *Surprised* Yes, yes there is.

Anyway, what have I done in the last little while and what will I do in the next 5 days, in terms of med school interview?

Last week, a friend of mine and I each organized a mock interview, hers at her apartment, and mine at some classrooms on campus. Counting the other practices, I've had 4 runs in total, and really, I think that's enough. If you haven't tried reading the question prompts and answering under time pressure, I strongly recommend you do so. Don't do it by yourself; best to find current med students or friends who are interviewing, but if that's not available, find other friends and family. Just ask them to sit there, keep time, and listen to you talk for 7 minutes.

I'm also reading some books on medical ethics, and I will probably read up on the rural medical issues. The book I am reading is called "Doing Right", by Philip C. Hebert.

Here I'd like to stress how previliged and thankful I feel about having an awesome supporting team of around 10 interviewing students. There is very little sense of competition among our group; we genuinely want each other to do well, giving the best feedback and suggestions we can give to each other. Also, I couldn't find that Doing Right book in bookstores and ordering it would take a month, so I sent out an email to this group for help. Within 24 hours, 3 people replied offering to lend me the book.

Anyway, in the next little while I'm just going to take it slow. Read the stuff I plan to read, do the school work I need to do, and on that fateful Sunday morning sleep in until 10am if I can, get a nice big brunch, take a walk around, shower, change, and drop the bomb.

[Interview] Mock MMI: tips I learned, and why I LOVE MED STUDENTS

Tonight, I met some 1st and 2nd year med students at 6:45, who organized a mock interview with 10 stations for 14 of us. It's now 11:30, and I just got back, being dropped off by a super awesome interviewer who stayed and talked to the very last anxious interviewee.

I'm so thrilled by this process and how much I learned, that I'm now typing this up fast -- still in my suit because I don't have time to take it off.

So, firstly, these are what I learned:

1. Avoid the law. Some situations are complicated with legal consequences, such as when your patient died, but the reviewing committee wants to see your empathetic response. How you feel for the patients, how you express your sincerity, how you approach the situation with warmth and honesty. Screw the hospital protocols; be the genuine, caring person that you are.

2. A big part about being a doctor is educating the patients. When the patients or your friends have some stuff that needs education, take that opportunity and tell them the correct information. Don't assume they are joking when they think STD stands for standard deviation.

3. Explore both sides of the argument when two conflicting sides exist. Even when you are clearly in favor of one side, if there is a dilemma, there has to be a strong argument for the other side as well. Explore that side of the situation and explain why you disagree with it.

4. Explain the thinking process; for questions that clearly does not have a right answer, the answer is not what's important, how you reach your answers is. Explain what's going through your mind, what values are being weighed on.

5. Explore all relevent areas of the question prompt. When the prompt asks for "what are the issues involved", think about who's involved, who's feelings are affected, what are the consequences of your decisions.

6. When the interviewer asks "do you have anything to add", don't take that as an invitation to babble on. If you reached your optimal, stay there and don't distract the interviewer with repetition.

7. Talk in an appropriate tone for the station. Some stations are more creative and fun, while some are more serious and heavy.

8. When a procedure fails, be mindful of the well being of the entire team: the nurses, the anaesthetist, everyone involved.

9. Read up on the Canadian Medical Association Journal for information on rural doctor shortage: rural doctors are actually getting paid more, but still there is a serious shortage, so the financial incentive is obviously not effective on its own.

10. When wearing a suit jacket, the last button should be undone.

[Interview] Practice MMI: Placebo Effects

Placebo (Ethical Decision Making)

Dr Cheung recommends homeopathic medicines to his patients. There is no scientific evidence or widely accepted theory to suggest that homeopathic medicines work, and Dr Cheung doesn't believe them to. He recommends homeopathic medicine to people with mild and non-specific symptoms such as fatigue, headaches and muscle aches, because he believes that it will do no harm, but will give them reassurance.

Consider the ethical problems that Dr Cheung's behaviour might pose. Discuss these issues with the interviewer.

* * * 

Outline: 

- ethics in informing the patient

- placebo effect as reassurance is trickery and undermines physician-patient trust

- using useless drugs may make the patients feel treated, and they do not have to follow other measures to improve their non-specific symptoms

* * *

Response:

Although the goal of doctors is to improve the well-being of the patients, physically, mentally, and emotionally, I believe that using placebo effects to trick patients into a false sense of safety and reassurance is unethical. It may be true that placebo effects sometimes are real; the mechanism of psychology affecting physiology is poorly understood, but not unheard of. And sometimes the patients may even demand the drugs that they believe are useful.

Despite that, I will explain two reasons why using placebo effect may be unethical, and propose a better approach to dealing with these patients.

First, using the psychological effect of placebo to sooth the patients is at best a well-intended lie. It puts the patient's trust for this doctor and even the entire medical system at jeopardy, since the patient may find out that the drug he or she was prescribed has no effect to improve his or her conditions. 

Second, even if the patient does not find out the ineffectiveness of the prescribed drug, providing him or her with this false sense of security may undermine other efforts to improve his or her health. For example, if the patient is reassured by the placebo for fatigue, he or she might ignore the suggestion to quit smoking, which may actually be the root cause of his or her fatigue.

In the situation when the cause of the patients' symptoms are ambiguous, the physician should be honest and open about the ineffectiveness of placebo, and suggest treatments that are actually beneficial for the health of the patients. These may not even need to be pharmaceutical; for non-specific symptoms that do not have medical treatments for, suggestions for a healthy life style such as regular exercise, a balanced diet, and adequate rest would be more beneficial for the patients.

[Interview] Rules of the Game: Multiple Mini Interviews

I think by now we all know what MMI is, if not, it's a lot like this:

Basically, this is like speed dating but with very serious dates who grade you not on your looks but on your character. (Hm... my own metaphor intrigues me... which type of dates would I prefer?)

The above is the official description. But like everything else med school-related, there are abundent myths surrounding the details of this interview process. Here is a list of them and what I gathered:

Myth: the interviewers are not allowed to respond to you in any way, including nodding. They are not allowed to say a word, so basically you are talking to a video camera with a human face.

What I gathered: the interviewers are not allowed to talk to you about anything unrelated to the question. But they can ask you things related to it, so to probe your thoughts and keep the conversation going. I think it's true that they are not allowed to nod though, so it would be kinda weird.

Myth: it's better to keep talking, because otherwise the room will fall silent and awkward.

What I gathered: if you run out of things to say, the room will fall silent and awkward. I have a friend who stopped talking and stared at the floor with the interviewer for 2 minutes until the time is up (the interviewer was not allowed to keep talking or write down notes in the presence of the interviewee, so he had nothing to do either). But I think that's better than rumbling on with the same thing over and over again and muddle your arguments.

Myth: there is nothing you can do to prepare for the MMI becaues you will never know what the questions are.

What I gathered: the skills to read the question under pressure, synthesize a well structured oral response in your head, and articulating your thoughts precisely and concisely may be much more demanding than you thought. It is actually quite easy to stare at the question prompt and waste your 2 minutes, and be completely confused and nervous in front of the interviewer.

My solution: practice with mock MMI's.