Saturday, June 17, 2017

Speaking For The Dead

If a suicide can't shake the medical training system into action, nothing will.

The motto of the Coroner's Office is, "we speak for the dead to protect the living." Unlike a police investigation into a homicide, say, coroners aren't out to assign legal responsibility or solve a crime. The goal is to identify the system failures that led to a death, and help find a way forward so it doesn't happen again. It's work that seems out of place these days, pressured as we are to make maximally productive use of time. It demands time and careful thought, reflection and patience. The problems can't be explored 140 characters at a time, any more than they can be addressed in a political news cycle. But because the work is on behalf of the dead, it's wholly incorruptible.

With a coroner's eye and heavy heart, I read the devastating story of Dr. Robert Chu, who died by suicide in September 2016, having been twice unsuccessful at landing a residency spot after med school. Those closest to him will spend years wondering what signs they might have overlooked, or what offhand remarks they might have misinterpreted, his family members carrying that burden the rest of their lives. But the personal details never tell the whole story, and Robert's death must be considered with the utmost seriousness by every medical educator and administrator in the country.

And to those who might brush it off as "just another suicide, what makes a doctor so special?", I would only point to the (admittedly crass) fiscal math. Canada invested roughly a half-million dollars - more than a decade's worth of the average family's total tax bill - to make Robert Chu a doctor, and he died before signing a single prescription.

What questions come to mind when reading Robert's story, and the accompanying piece in the Toronto Star about the plight of other unmatched medical graduates, outside of whatever personal factors played a role? Many that give pause for thought, and light the way for decision-makers to act.

In his first go-around at the match, Robert was told he was too broad in choosing his electives, perhaps at the expense of focusing on radiology (the article isn't entirely clear on this). Is an early narrowed focus something we should prize in medical students? What about people who discover a specialty late in medical school, or change their mind because of an excellent mentor?

In his second go-around, Robert's sincere interest in psychiatry was questioned because of his past publications in radiology. How did research credentials suddenly become a detriment, in particular as so many medical students have done undergraduate research that is utterly irrelevant to their future practice? And why wouldn't a program take an applicant at face value? Is it not possible to "grow into" a field of medicine? Not every doctor is a journeyman, but interests change and passions are uncovered as one's experience grows. Who's to say Robert wouldn't have been happy as a psychiatrist, and serving the public with the utmost competence and professionalism?

When Robert wasn't matched, why the stonewalling with regards to feedback his unsuccessful application? If the fear is that such sharing of information could lead to "gaming", isn't it past time to overhaul how applicants are selected? Is there too much emphasis placed on subjective factors? Do residency program directors need to face the possibility that they, too, are susceptible to unconscious biases in their selection processes?

Looking back on my own career, and listening at length to friends and much more experienced colleagues, it's long past time we revisit the current system of having medical students choose their field of practice, with little in the way of wiggle room should they have a change of heart. This has contributed to both the generation-old maligning of general practice, and the present crisis of disinterest in family medicine. The policy response to this is necessarily a radical one, but that doesn't make it less worthy of consideration.

More than 100 graduates of Canadian medical schools will be without anything resembling the prospects of their friends and classmates as of July 1st. Some will have found employment or academic work and ultimately land on their feet, but others will be struggling in circumstances they never foresaw and cannot control. Counselling and "resiliency" training are a perfectly fine band-aid, but nothing approaching a cure for the underlying problem. Now that one graduate has felt desperate enough to see death as the only escape, how long until another promising doctor does the same? Do we as a medical community dare accept it?
"Without a residency position, my degree … is effectively useless. My diligent studies of medical texts, careful practice of interview and examination skills with patients and my student debt in excess of $100,000 on this pursuit have all been for naught"
Dr. Richard Chu's voice fell on deaf ears in life. It's up to all of us to speak for him in death.

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