Thursday, May 17, 2018

The Death and Life of Canadian Medicine, Part VI

Tending to our many, often self-inflicted wounds.

Previously: Part I, Part II, Part III, Part IV, Part V

Any essay on health care reform is at best an exercise in harmless fantasy, and at worst an exercise in arrogance. No matter how informed one might be by an understanding of history or a grasp of present realities, the picture is never complete, and foresight is nowhere near as perfect as hindsight. The healthcare system is also more resilient than we often give it credit for, or at least it's resilient when the Powers That Be open the money tap.

Still, medicine in Canada seems to be at a critical juncture, even if we overlook the major problems - hospital overcrowding, wait times - that threaten the integrity of the system as a whole. Doctors aren't practicing in the manner the public seems to need or expect, but working and training conditions are as bad as or worse than ever. Assuming that nobody's happy with the status quo, what should the Powers That Be do?

Doctors need a job description. Not pie-in-the-sky vision statements that read like the character sketch of a tireless saint, but clear, unambiguous expectations for every field of medicine. Everything the system struggles with when it comes to doctors - focused practices, poor geographic distribution, boutique medicine - boils down to the absence of a functioning job market. A job market can't be created, analyzed, maintained, or reformed without a job description for each and every specialty.

There must be a commitment on the part of policymakers to pay for the creation of, and transition to, a job market. Why do governments come up with overly bureaucratic micromanagement schemes to get doctors practicing where and how they dictate? Because they don't like the idea of paying to employ doctors. Why pay salaries, when you can restrict billing numbers or put volume demands on doctors that pay their own office expenses? Except that this strategy doesn't work, any more than throwing more money into rural incentives or after-hours bonus payments. It just leads to more unintended consequences, money spent poorly, and more mercenary-like care in underserviced communities by doctors that come and go every few years.

It's time to phase out fee-for-service medicineMedicine just isn't what it once was, and the doctor that worked dawn-to-dusk seeing upwards of 40 people a day with acute problems is a relic of the past. Even surgeons no long deal with straightforward acute problems, but increasingly older patients living with chronic, multisystem diseases. We simply can't plan essential services like diabetes care, stroke rehab, labor and delivery, or ER coverage, and accommodate the needs of doctors wanting a semblance of balance in their lives, under a business model at least a quarter-century out of date.

As recently as two years ago, I was of the mind that even family doctors could thrive in relative entrepreneurial-style independence. Given the unaddressed crisis in family medicine, and unapologetic approach by governments to impose work requirements on doctors, I personally don't believe fee-for-service self-employment is still viable. That doesn't mean doctors should be universally on salary. Rather, a combination of salary-like payments and session fees, with benchmarks and incentives, is the way to go. Government should assume office overhead costs by financing municipally-built and run community facilities. Doctors in practice content with fee-for-service self-employment may carry on as they do. But new doctors, or doctors that get off the treadmill and take jobs in government-financed facilities would stop receiving payments through billing (with billing numbers to serve a dummy role, for tracking and referrals). It might take a generation to get it all working properly, but better that than the mess we're in now.

It's time to shake up who gets into medical school. I don't mean putting more effort into recruiting rural students, or women, or persons from marginalized communities. That's already happening, and the health care system will only be the better for it. Rather, it's time to de-emphasize undergraduate science as the best pathway to medicine, and do away with requiring the MCAT at all. Medical schools should work with undergrad universities to develop a better set of prerequisite courses - offhand, I'd suggest physiology, statistics, and ethics as a starting point for discussion - and encourage people from broader areas of study to consider a career in medicine. How many doctors discover a passion for history later in life? Or craft great works of literature? Or art and music? Or take up fellowships in journalism? Why should that door swing only one way?

Get the residency game out of medical school, and break down the wall erected between Family Medicine and specialties. If there's one thing almost universally agreed upon about med school, it's that med students don't get sufficient exposure or counseling to make an informed career decision. Nevertheless, decide they must what field to pursue, so perceptions around money, lifestyle, and prestige replace a real understanding of societal needs, appreciation of one's own strengths and interests, and a feel for the realities of the job and job market. Worse still, what was intended to be the default career choice for med students - Family Medicine - is unwanted and widely derided.

The solution is to take the decision out of medical students' hands. The old rotating-type internship worked in the past, but medicine is too complicated now to be practiced after a single year floating around a hospital. Putting the residency match after internship will lead to better decision-making, but that too is subject to the same sort of gaming. Instead, we should take advantage of the revolution in medical training based on objectively measurable competencies to let doctors find their place and meet the demands of the job market.

Instead of choosing their specialty with almost no clinical experience, have students apply to one of three streams for their post-graduate training: clinical, surgical, or diagnostic. The first post-graduate year would be largely rotating, the second a mix of mandatory and selective rotations. Depending on what the trainee chooses to focus on, he or she can apply for further specialty training, pursue certification in Family Medicine, or obtain a general license for work as personal interests and the job market demands (clinical associate, surgical assists, hospitalist), with opportunity for re-entry down the road.

Why these three broad categories? For one thing, the motivation to be a surgeon (and I include Obstetrician-Gynecologists in that category) is something people have or don't have. Med students might not know if they should pursue Urology or Vascular surgery off the bat, but the surgery itch is unmistakable. As far as the scientific-diagnostic fields, people bound to enter Radiology or Nuclear Medicine or Pathology have a good sense of not wanting much clinical contact, but the job market is always evolving, with technology driving entire new fields of sub-specialization.

And so many communities have different needs, it seems premature for future clinicians to shoehorn themselves into one specialized field at the expense of everything else at such an early point in their careers. What if Primary Care isn't appealing to a student, but Mental Health and Emergency Medicine are? How do you make the case for yourself when applying to a Family Medicine program? Or must you choose between an application to Emergency Medicine and Psychiatry programs?

What if you have a clinical interest in Respirology, but want to treat both adults and children? Do you train primarily in Pediatrics or Internal Medicine? And if you have a research interest that straddles two or three different fields, say Neurology and Psychiatry, how do you select one specialty over another? Is it realistic to expect a third or fourth year medical student to appreciate the differences in these residency programs?

The immediate response to this kind of suggestion, in particular the suggestion of a "general license" as opposed to proper certification, is that such a system devalues Family Medicine. My response is twofold. First, a functional job market addresses the downsides of Family Medicine that stem from fee-for-service self-employment. And second, Family Medicine is *already* devalued, and has been for more than twenty years. All the fretting over the "hidden curriculum" and "need for better mentors" has changed nothing. The discipline must change, or it will face wholesale replacement by Nurse Practitioners and other health professionals.

Making residency less awful. Of all the aspects of life as a doctor, culture is and always will be the most difficult to change. A government can tax, borrow, or print all the money it wants to enact whatever policy it wants, but a person's heart and mind can only change if he or she wants it to. But there are concrete steps we can take to make post-graduate training somewhat more palatable.

There needs to be an honest, evidence-informed discussion on how many hours residents should work in a week. No more machismo like, "the downside of 1-in-2 call is that you miss half the good cases". No more grumpy-old-man, "in my day, we did 36 hours and we liked it!" rationalization. Instead, a consensus must be reached to balance the service needs of the teaching hospitals, the safety of the patients, and the family life and mental health of the residents. If it means we train more doctors, then we do it. If it means we train more foreign grads to fill the call schedule, then we do it. Residents shouldn't be coddled, but inhumane working conditions helps nobody.

And medical schools should make a point of identifying people to serve as so-called "organizational priests/priestesses"...veterans of the system with no professional or educational authority over residents, that residents can meet with regularly to keep tabs on their mental and emotional well-being. Every medical school needs someone like this to watch over residents, or the position can be created in conjunction with the provincial medical association.

Of course, I'm in no danger of being appointed a "Czar of all Health Care". As I noted above, most ideas to improve medicine and health care, whether trivial or grand, half-baked or planned to the most minute detail, rarely amount to anything. The institutions of Canadian medicine and Canadian health care work under their own (glacial) momentum, all too often serving no needs but their own.

Still, as I'm now in my second stint of playing the patient rather than the doctor - or at least, waiting for my second stint to play the patient (now THAT'S Canadian health care!) - I can't help but notice that the future of Canadian medicine seems uncertain, even perilous. Will doctors seize control of the profession's own destiny, and lead the charge in making desperately needed reforms?

1 comment:

  1. Well written. Your last sentence hits the mark and aligns with the CSPL's white paper, calling doctors do get engaged in redefining their role in a fast changing health system. http://physicianleaders.ca/assets/whitepapercspl1003.pdf

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