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It’s time to rethink medical education in Canada

A version of this commentary appeared in the Globe and Mail, Waterloo Region Record and the Guelph Mercury

Female medical worker looking awayIt was only a decade ago that headlines in Canada were filled with pessimism about the nation’s critical doctor shortage. Wait times for specialists were increasing, doctors were leaving for the U.S. and patients couldn’t find a family doctor. Yet a recent study from the Royal College of Physicians and Surgeons of Canada notes that today, one in six new health specialists cannot find work.

Surely, this must be disheartening for recent graduates, who, after 10 to 14 years of post-secondary education, are underemployed and saddled with huge debt loads.

Can we at least take solace in the fact that our health system has improved as a result of this big investment in medical education? Unfortunately, the bright spots are hard to find.

Let’s look at the regional distribution of doctors in Canada. In rural and remote areas across the country, access to specialists remains a huge barrier. A quick check of the Ontario government’s website, for example, shows that wait times for orthopedic surgery is 261 days in Thunder Bay, compared to about 110 days in Toronto. We have more doctors, but not necessarily where they are needed most.

What about quality? In my past research on the perceived physician shortage in 2002, I found that the single biggest factor behind the drop in doctor supply was the decision by certifying bodies to increase the length of training for most specialties. The presumed justification for this was to improve physician skill, which in turn would improve quality of health care.

The problem, however, is that most quality defects are not due to lack of provider skill, but to poorly organized patient flow, poor communication and poor teamwork. One in fifty patients in hospital is harmed unnecessarily due to the care they receive. Best practices — such as ensuring the right drug or test is done at precisely the right time  don’t happen about half of the time.

These quality problems exist not because doctors are not well trained, but because health care has become so complex. It is easy for the human mind to forget to do the right thing, be distracted, or lose track of all the pieces of information that need to be communicated. Tools, such as electronic medical records that provide reminders and prompts, communication protocols, checklists and standard processes like what airline pilots use when they take off and land, are what the health system needs most.

Increased length of training may have also hindered the flexibility of our workforce, just when flexibility is at a premium. Medicine will soon face a wave of disruptive technologies driven by genetics, consumer-accessible devices and micro-implants. Already, heart surgeons face tough job prospects because better cardiac stents have reduced the need for cardiac bypass. Soon, gastroenterologists will lose their bread-and-butter colonoscopy, replaced by pill-sized cameras that one swallows. Right now, I can buy attachments to my iPhone that let me do an electrocardiogram or ultrasound. While such devices will never eliminate the need for specialists, they may dramatically change which specialists are needed and how specialists are used.

Clearly, our medical education system needs to tackle some tough questions if it is to do a better job of serving the public. Will we continue to do most specialty training in urban centres, or will there be the political will to dramatically shift training to smaller, underserviced communities? (Most studies show that doctors tend to practice close to where they were trained.)

Could we shorten residency training, by focusing more on demonstrated skills rather than time spent in the program? Do we still need rigid boundaries between specialties, or could more procedures be shared by different specialties, family doctors or other professionals, to increase flexibility to meet local needs? Will formal residency-style training continue to be something done mostly in one’s early years, or rather something done in short stints several times throughout one’s career?

Lastly, and most importantly, are our medical educators prepared to submit to a national strategy for managing health human resources? It’s clear we need one.

These solutions are tough to implement, because some training programs will need to “give up” something they already have  students, funding, autonomy, or “clinical turf”  while other programs gain as a result. Governments and the medical establishment will need to work together and set aside vested interests to maximize the public good. It’s not an impossible task, but an essential one, necessary for the health of Canadians.

Dr. Ben Chan is an advisor with EvidenceNetwork.ca and Assistant Professor at the University of Toronto. He practices family medicine part-time in remote communities in Northern Ontario. From 2003 to 2012, he was the CEO of the Health Quality Councils of Saskatchewan and Ontario, each responsible for monitoring quality at a provincial level.

October 2013

This work is licensed under a Creative Commons Attribution 4.0 International License.