Summary of proceedings: The first set -- Report to plenary session, May 5, 1997 Stuart M. MacLeod, MD, PhD Clin Invest Med 1997;20(6):422-7. Dr. MacLeod is professor in the Departments of Clinical Epidemiology and Biostatistics, Medicine, and Paediatrics, Faculty of Health Sciences, McMaster University, and Director, Father Sean O'Sullivan Research Centre, St. Joseph's Hospital, Hamilton, Ont. Reprint requests to: Dr. Stuart M. MacLeod, St. Joseph's Hospital, 50 Charlton Ave. E, Hamilton ON L8N 4A6 Contents Introduction First plenary report: key issues in undergraduate medical education Key issues in postgraduate medical education Key issues in continuing medical education Key issues in specialty health care Key issues in primary health care Key issues in research Conclusion Introduction These annotated summaries reflect the plenary discussions that followed active workshop debates on several topics relevant to change in medical education. The summaries reflect key issues raised, edited for conciseness. All points identified in the actual sessions are recounted but further clarification has not been sought or added. A summary of this kind cannot present all dimensions of the issues raised; however, the outline is presented as a work in progress and as a stimulus to further necessary discussion. A more complete version is available on audiotape. [ Top of document ] First plenary report: key issues in undergraduate medical education Consumer/student empowerment: There is a need to examine new ways of defining trust relationships between faculty and students to reflect the changing interaction between physicians and health consumers. Power relationships have changed. Individual consumers and communities expect a greater say in health care. Students must be taught that they will not, in future, be able to say, "You're going to do it that way" without support of rational argument. There is an added level of discomfort evident today stemming from the fact that students are often ahead of their faculty mentors in accepting the new paradigm. Changing relationships with other health care professionals: The future emphasis is likely to be on multidisciplinary teamwork. Students must be taught to recognize the complementary expertise of others in the medical school environment (nurses, rehabilitation specialists, pharmacists, librarians, biological scientists, epidemiologists, statisticians, etc.) Added pressure may come from the need to recognize and understand contributions to care from practitioners of alternative and complementary medicine. Changing practice expectations: Present-day medical students are entering a career pathway with new expectations of professional lifestyle. They foresee a future in which working conditions are much more consistently controlled, with hours of work limited; however, patient expectations have not yet diminished and 24-hour service is demanded even in remote and rural locations. Faculties must play a role in reconciling the dichotomy between patient expectations and the now-predictable future pattern of professional practice. Mismatch of faculty experience to future needs: The current medical school faculty complement reflects an earlier era and is not entirely appropriate to changing practice realities and scientific supports. For example, most clinical faculty are tertiary care specialists and may be uncomfortable or ill-equipped to serve as role models for practice in community settings. Similar discordance is apparent in research: basic science departments have become increasingly molecular, while the need for epidemiology and probabilistic scientific inputs are paramount. Changing funding sources: As support for undergraduate and graduate education comes increasingly from sources other than public funds, the mix of students will probably change to reflect a broader base, with most students able to pay for their education. One example of this will be the recruitment of students from developing countries on a full cost-recovery basis. Changing information paradigms: The amount and quality of health information available to patients is changing rapidly. At the moment, at least, the physician must play a central role as interpreter of that information and arbiter of the scientific evidence on which it is based. This represents a new role for physicians in working with individuals, communities and even health policy-makers. There will be expanded emphasis on the development of evidence-based resources for practitioners, students and patients, emanating from the academic health science centre. Use of technology: New technology should be a means to an end, not an end in itself. Technology should be used to promote communication rather than be allowed to create a barrier to communication. Institutions need to accelerate their matching of educational programs to the development of information technology. Computer skills should be recognized a necessary part of literacy in the broader field of informatics, but should not be the only ingredient. Undergraduate curriculum of the future -- priorities for revision: The undergraduate curriculum must evolve to reflect new realities, including those discussed above. The content should reflect the need for future medical students to acquire certain skills: comfort with informatics; an aptitude for retrieval, evaluation and application of knowledge; an ability to identify the best information sources; an ability to deal with uncertainty; comfort in assessing emerging, alternative (complementary) treatments; capacity to assess cost-effectiveness; and communication skills and expanded capacity for listening. [ Top of document ] Key issues in postgraduate medical education Faculty development: There is a need to change the capacity of postgraduate faculty to respond to changing societal expectations. The public no longer looks unquestioningly to doctors as the sole source of expertise in health-related matters. There is also a demand for "caring" to match the "curing" ability and an expectation that the right kind of doctor will be available in the right place at the right time. Formal faculty development programs are required, with the aim of fine-tuning the attitudes of those positioned to influence postgraduate trainees. Educational activities, care and research must all be responsive to this changing orientation. Little will be altered unless the faculty is prepared to create a fertile place for students to practise in accordance with changing attitudes. New role models: Postgraduate programs must provide role models of the new healing/caring variety of physicians, without abandoning the spirit of scientific enquiry embodied in the clinician scientist model. Part of the new reality is a recognition that doctors need time for reflection as part of their professionalism. The new model must also recognize the diverse cultural needs of patients and colleagues. Perhaps more important, it is time for a cultural sea change in medical schools, with a de-emphasis of the current preoccupation with the financing of medical practice. There should also be a reorientation to scholarly pursuits and an effort made to mesh the interests of research with the broader aims of the healing/caring practitioner. If real changes in role model are to occur, it will be necessary to change medical school governance and the reward system that now drives academic priorities. Formal instructional models: Innovative postgraduate education demands a new package of instructional tools that will recognize: diversity, new role models in caring, new attitudes to collaboration, a new research orientation, a new system of reward and incentives, a need to adapt to the changed environment in teaching hospitals for experiential learning (for example, in this era of day surgery, when will surgical residents learn to assess patients?), opportunities afforded by improved communications technology, roles of doctors as teachers and communicators, the need for residents to understand learning theory, the need for emphasis on patient-centred teaching, the need to understand the organization of the health care system and the process of health care reform now under way, and The need to balance the timing of healing and caring elements in the instructional program. Credibility gap: There is an apparent discrepancy in research, education and clinical care between the stated goals of academic medical centres, favouring collaboration and caring, and the reality, as reflected in their response to the priority goals of universities, governments and professional organizations. Medical schools are sometimes seen to be as shockingly bereft of clothes as any mythical emperor or opportunistic minister of health. Improved postgraduate education requires that academic centres learn to "walk the talk." [ Top of document ] Key issues in continuing medical education There is a need to facilitate institutional and personal adaptability, in keeping with the process of very rapid change in societal expectations. The economics of continuing medical education are problematic. Universities do not fund this area adequately and it has been difficult or impossible to make such programs self-supporting. Key indicators of academic performance generally ignore the analysis of continuing medical education's impact on the practice community. Continuing medical education is trapped by the rigidity of professional expectations, making it difficult to respond to increasing societal knowledge about health and changing public demands for medical care. We need continuing medical education that will enhance decision-making capacity, e.g., maximizing flexibility and adaptability, using informatics more fully, placing of guidelines appropriately, and emphasizing evidence-based care. Improved continuing medical education would aid in efforts to deal with the maldistribution of doctors and with the pressures resulting from population shifts. Enhanced continuing medical education activity would encourage medical schools to perform more like "learning organizations" and to foster partnerships in the educational process. Continuing medical education should be seen as an instrument to energize practitioners and to help them become motivated to cope with change in the health care environment. [ Top of document ] Key issues in specialty health care Academic health science centres should discourage the notion that medicine is a monolithic profession. There is a need for better data from Canadian sources to guide human resource planning. The Association of Canadian Medical Colleges (ACMC) should lead this activity, recognizing a responsibility to guide students into specialties where demand is greatest. Alternative remuneration plans and rostered care will create new patterns of demand for primary, secondary and tertiary health care specialists. ACMC should keep a careful watch on the impact of provincial initiatives that may indirectly render some practice specialties nonviable. Further exploration is required of the relation between financial support for undergraduate/postgraduate training and freedom of choice in eventual practice location. Faculty members should be better informed about these issues and their impact on practice choices by students. An issue of key concern to the ACMC is the career structure and funding of academic physicians. There are experiments in place in Toronto and Kingston, and under discussion in Quebec, in which academics' salaries are no longer linked to service provision. The future for academic physicians is probably one in which they will receive direct payment for services in education, research or clinical care. Salaries in the models under exploration will be set in accordance with specialty, work expectation, hours on call, educational and research responsibilities, etc. Some specialists are being torn mercilessly between hospital and community responsibilities. There is a need to clarify plans for continuity of care so that specialists can be trained for roles unclouded by ambiguity. This is another dilemma deserving consideration by the ACMC and the Association of Canadian Teaching Hospitals. [ Top of document ] Key issues in primary health care Primary care physicians are the vital channel by which patients gain access to knowledge with a broad base. This educational function must acknowledge and respect the roles and responsibilities of other health care professions. The primary care physician's traditional gatekeeper role should be modified to a facilitator/coordinator/communicator role. Battles over hegemony with other health care professionals should be avoided. The ideal of teamwork should be promoted; it should be recognized that the achievement of this ideal will require a unified patient record and a better use of information technology. Integrated care is really an information issue. Population-based funding, by providing necessary incentives, will prove to be the cornerstone for establishment, maintenance and enhancement of an improved primary care system. Outcome measures must be seen as an integral part of the choice among delivery models in primary care. Change for the sake of change should be discouraged. Integrated leadership is lacking in primary health care reform. We are currently witnessing piecemeal initiatives by provincial governments and professional organizations. There is a role for leadership from the medical education domain in this area. [ Top of document ] Key issues in research Priority setting would be aided by establishment of a National Science Policy Board to define broad research needs and goals. It should be recognized that Canada has a poor track record in setting and achieving scientific goals. There is a need for a better inventory of existing health services research and for analysis of gaps in current activities. Research implementation warrants careful consideration from a medical school perspective. How will priorities be determined? How will resources be allocated? How will research be made responsive to local needs? How can we profit from the tensions among potential partner groups in health services delivery research? Funds are required to support research training in primary care to achieve integration and a continuum of research in the community. A way must be found to address public expectations of increased accountability from researchers. To what extent should the research agenda respond to public demand? There are some opportunities for the academic research community to capitalize on the changing environment: to bridge effectively between family medicine practice and research, to promote links between research and continuing medical education, to encourage the development of public policy based on credible research, to study behavioural change by health caregivers in response to research evidence, to promote the integration of social science research, and to promote regional or national academic networks in order to encourage proactive interaction of stakeholders. [ Top of document ] Conclusion This session was perhaps best summarized by 5 perceptive comments made from the floor. David Keegan: I actually heard a question in the report from the specialty health care group, and the question was, "Students and residents say they have the right to go where they wish; where do they learn this?" I don't want a soapbox, but I might answer on behalf of the Canadian Association of Internes and Residents. It's not a question of current students and residents feeling that they have a right to a full-time job with 100% patient lists wherever they want. Trainees do feel that they have a right to equal opportunities. So if a job in orthopedics with some OR time opens up in Toronto, then a new trainee should have an equal right, along with other surgeons, to be able to apply for that position. If you are a family physician, you have the equal right to practice. That doesn't guarantee patients. As a matter of fact, in St. John's, before the 50% billing disincentive was introduced, you could open up a practice and find it necessary to work very hard, nights and weekends, to attract even a reasonable number of patients. It's the equal access which is the important issue. Where do we learn this? We learn it from all prior MDs. Really, the problem is caused by the cohort of MDs who are in practice, not by the current trainees. So if you look at it conceptually, why should the current trainees be the only target, by coercion, to fix the problem of all previous MDs? It makes you wonder. There are solutions that are more equitable: re-adjusting fee schedules to favour those who work in underserviced areas or do work that is underprovided, for example. Of course, there are many professional and personal issues in regard to rural areas that need to be addressed: locum coverage, CME coverage, various support mechanisms, good referral systems, and so forth. What trainees really want is a right to practise in an area where they can expect a good practice environment, and to be treated equally with other physicians. Adrian Jones: As a part-time hospital administrator with a GFT background, I'm a little bit surprised that, in the postgraduate group, no mention was made of the extraordinary changes which are occurring in teaching hospitals and other hospitals right now in regard to the exposure of residents to patients. We speculated in our group that, in fact, a senior surgery resident might only recognize a patient if the patient had his belly open when he walked into the office. Close to 70% of elective surgery in our area is now day surgery, and virtually all of the rest of it is same-day admission. The Royal College of Physicians and Surgeons and the College of Family Physicians of Canada need to do a major rethink of the paradigm of training for postgraduate residents under the new conditions of health care restructuring, in which there are far fewer beds and the length of stay is very different. Far more care is now occurring in the community in subacute, long-term and alternative care. We, as health care administrators, still need the patients looked after. As residents potentially move into other areas for their training, we may be left with fewer people on the wards doing very high-acuity work on patients who are there for a short time. We need to understand that balance between the educational needs of trainees who have previously been very much expected to do service as they got their education, and the service that we must guarantee for the patients who are coming in to the hospitals. Anne-Marie MacLellan: I think that we must continue to train both family physicians and specialists to a level of appropriate medical expertise. I worry that, with the dilution of experience, the many, many changes that are happening, the closures of ORs, the limited OR time, and perhaps more community experience in certain areas, that we must continue to train our residents to be specialists. If we don't train an obstetrician to have the proper technical skills, or a surgeon to have the proper technical skills, we haven't done our job right. It's true there is the healer role, but there are a lot of other health professional groups that would like to take over, and can take over certain of the things we are doing. So we must ensure that our physicians are very well trained so that the public will continue to respect us. The next thing I'd like to say in support of the students and residents is that the four postgraduate deans in Quebec have met to talk about the phenomenon of people leaving specialties to go into family medicine. I think it's very important that people listen to what the students and residents are saying. They are questioning why they should go through, let's say internal medicine, 4 years of medical education, 3 years of internal medicine, 2 years of a subspecialty, plus another research year to find, after all of that, that there is difficulty in finding jobs. They can't get research grants. They have a high level of indebtedness. There are certainly lifestyle issues. Another issue is portability of licensure. They are all very worried about different provincial governments clamping down on billing rights, so that they will be left high and dry with even fewer opportunities. Sister Elizabeth Davis: I think one of the things I see through all the groups is an underestimation of the power of the Internet and the kind of information that is on the Internet. This influences how the public perceives us as health care professionals and how the public perceives the medical profession. We are somewhat inward-looking within health care, even though we may be getting better at working within the system among ourselves. We are still, however, very inward-looking and filled with angst about change. In our lack of clarity about where change will lead us, we are forgetting why we are here in the first place: to serve the needs of the greater public. Second, we are underestimating what is happening within that public in terms of their information base. Whether it's valid or not, reliable or not, is irrelevant. The public now has immediate, inexpensive access to an all-pervasive information base, which they have never had before. What I fear is going to happen is that, unbeknownst to us, because we are so busy looking at ourselves, there is going to be further erosion in the public's confidence in the health care system in this country. We are going to wake up one day to be shocked at how deep that erosion has been. Jean Gray: I was a little surprised that the research discussion group offered no support, or at least no obvious support, for the concept of funding of fundamental research. To put this into a different context, we can train thousands of musicians, who are our practitioners, and hundreds of instrument makers, who are our hospitals and health care deliverers, but if we don't have composers we don't have any music to play. I think the issue of fundamental research and the decline of support for fundamental research in this country, even though I know we've said it hundreds, if not thousands, of times, is a very important aspect of where we are going in the next century. | CIM: December 1997 / MCE : décembre 1997 | CMA Webspinners / >