Friday, May 4, 2018

The Death and Life of Canadian Medicine, Part I

From Ground Zero back to Square One.

Medical schools churning out record numbers of newly minted doctors, while clinics in the neediest communities can't even find vacation coverage. A shortage of doctors to run our country's desperately overcrowded ERs, while Colleges put ever-increasing expectations upon MDs looking to pitch in. Patients coping with agonizing waits for joint replacement, while orthopedic surgeons are unable to find jobs. Ballooning wait lists for cataract surgery, while ophthalmologists aggressively market refractive surgery.

Canada has never had a larger, more diverse, or more expertly trained medical workforce than it does today, but access for many seems to worsen all the time. Why? Why all the festering, worsening problems? Why do we see so many headlines and Tweets about unmatched doctors and unemployed specialists? Why does it seem like the job market for Canadian doctors is increasingly broken? More importantly, is there a hopeful way forward for Canadian medicine?

To dispense with the knee-jerk answers, it's not for lack of money, at least not money paid to physicians themselves. Money can help put otherwise idle surgeons to work, but that's money directed at hospital and operating room capacity, not training and hiring more surgeons and anesthetists.

Nor does the problem lie with single-payer health care and the perceived shackles of the Canada Health Act, the nigh-sacred law aimed at preventing "two-tiered" health care. The Canada Health Act is the source of more than its fair share of problems, but it doesn't much affect doctors' practice patterns, at least not in the more common, un-glamorous fields of medicine (Family Medicine, Pediatrics, Psychiatry, etc.)

No, the root of the problem is that for the most part, being a doctor in Canada is a set of credentials without a clear job description. And you can't effectively create or manage a job market if nobody's laid out what's expected of the people working in it, in terms of scope, location, hours, or anything else.

Instead of having proper job descriptions - though they do exist for some specialties - doctors in Canada are largely self-employed. They work under an organic and ever-evolving mishmash of traditions, scope-of-practice rules, professional standards, the "social contract" between the profession and the paying public, personal interests, government restrictions, and financial carrots and sticks. Things work well, or at least work predictably, so long as these (mostly unwritten) rules are followed in the same manner as the years go by. That's no longer the case, for reasons that range from a lack of foresight to competing interests to bureaucratic inertia to willful ignorance.

Unpacking these issues isn't all that hard, at least in broad strokes. Most of them trace back to the 1990s, when (largely) independent forces laid the groundwork for the "perfect storm" in Canadian medicine today: a radical shift in the training of doctors; changing demographics of the profession; government budgetary restraints; and the changing nature of medical care itself. But all that in due time.

For now, Canada and Canada's doctors desperately need to reach a consensus on first-order questions before worrying about - as these discussions so often devolve into - how and how much doctors are paid. Once the major decisions are made, questions of organization, the proper mix of specialties, logistics, and money can be reverse-engineered and negotiated down the road.

1. What do we expect from Canada's doctors? 

Are there certain services that should be essential for doctors to provide? Should some services be mandatory to provide if a doctor has been so trained? What about expectations around hours of work and after-hours services? How do we accommodate doctors' parental or caregiver responsibilities?

2. How much autonomy should doctors have in charting their own career path?

Is it fair on the one hand to say doctors must provide X services for Y hours a week to at least Z patients in location A, but then demand they be responsible for their own expenses? Is it fair or even wise to do that? Should doctors have a quota of some sort for public service?

3. Following on the first two questions, what should we look for in our prospective doctors?

Are we recruiting the right people into medicine? Or enough of them? Are they getting appropriate counseling and training at the right stages in their careers, from undergrad (or even high school) through residency?

4. Are we willing to pay for the transition to the kind of medical care system we want?

If, as a country, we decide that doctors are at least partially public servants, and must be part of a functioning job market, are we prepared to fund the infrastructure for it? To build capacity and hire nurses and train nurse practitioners? To dismantle centralized power structures that don't serve the interests of the public or the profession?

Clearly we're running out of cake for everyone to have and eat too. The situation is approaching a breaking point in Family Medicine, but systemic cracks are evident pretty much everywhere. But we shouldn't rush ahead without getting a sense of how we got here.

Next time: how medicine changed for good in the 1990s

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