Wednesday, January 3, 2018

Fail Me Once...

However a doctor's lawsuit over his residency program goes, is it time to rethink a tradition in medicine that looks more and more like an anachronism?

2018 will be another big year for medical-political news across Canada. Hospitals are dangerously overcrowded, threatening the stability of the acute care system. Provincial elections are scheduled in Ontario, New Brunswick, and Quebec. Alberta's agreement with its doctors is set to expire, and Ontario's doctors are now in mediation over a contract with the province, possibly but not certainly headed for arbitration. But those stories are all months away from unfolding.

The first big medical news story of 2018 (technically, the last story of 2017) is this one from the Toronto Star, detailing Dr. James Stuart's lawsuit against Western University for a lousy residency, an inadequate training program that led to his repeated failure of the Royal College exam. Since he didn't pass the exam, Dr. Stuart remains ineligible for independent small stakes for an MD.

The legal details of the case are way beyond my comfort (and discomfort) zone, so I'll leave the odds-making and legal analysis to the lawyers. That said, the potential ramifications are broad, but not so much so for medical residencies. There are a slew of accreditation procedures that residency programs are subject to, more or less continuously (my spouse is a program director, and it's a minor relief when someone besides me is the source of her stress). Rather, it's other professional schools that have reason to fear a court finding for the plaintiff. Royal College exams for doctors are largely formalities (more on that in a moment), with pass rates above 90% for almost all specialists. But accounting schools? The accountants' final exam notoriously failed graduates for decades, with first-time failure rates above 25%, though that's since improved since the introduction of a new exam. Can you imagine if every stumbling accounting student now had grounds to go after their school?

But that's not really relevant to the medical world. And we should not give in to the temptation to automatically assume Dr. Stuart was incompetent or unintelligent. He trained in Medical MDs in the laboratory medicine disciplines are free from the interpersonal headaches of clinical practice, they're often the most knowledgeable folks you'll ever meet. (Medicine's "dumb jocks" traditionally end up in Orthopedics for some reason.) 

There are two questions we should take from this story. The lesser of these is what should be done with a resident that finds him- or herself in a floundering program. The answer is fairly straightforward, if not its realization: get the resident into a different discipline in the same city, or a different program in the same field. Yes there's inconvenience and expense and dash hopes involved, but this is ultimately not a situation that's going to arise very often. There are just too many people and too many safeguards with most specialty programs.

No, the more important question is why a Royal College exam is needed these days at all. These exams, particularly the oral exams, are MURDER, not only for the young doctor but also his or her family. Marital strife, neglect of self-care, inability to spend time with children...all for what purpose?

An all-or-nothing stressful situation that will never arise in a doctor's career? Medicine isn't a sport, with the single throw, strike, or catch of a ball capable of determining one's entire legacy.

A final test of competence? Is the profession not engaged in a constant effort to improve how it imparts and measures competency? So we don't pin a doctor's career prospects on something as fleeting as a day of heightened anxiety? And if so few trainees fail anyways, why bother? And what about those training in sub-specialties of Internal Medicine? Are we not detracting from their subspecialty training by forcing them to spend months studying for an exam with little relevance to their practice?

We've come a long way since the days of treating post-MD training in the same manner as we do graduate degree studies. The practice of medicine, clinical or otherwise, has almost nothing in common with the singular focus demanded by the crafting and defense of an academic thesis. It's not that one is necessarily easier than the other. I found my own Master's studies more onerous than preparing for the Family Medicine certification exam. It's that medicine and academics are entirely different endeavors, demanding entirely different intellectual skills. It's long past time we asked whether the "age-old tradition" of an expensive and punishing exam isn't more trouble than it's worth, and should take its place alongside trepaning and phrenology in the dustbin of medical history.

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