Summary of proceedings: The second set -- Report to plenary session, May 6, 1997
Stuart M. MacLeod, MD, PhD
Clin Invest Med 1997;20(6):428-32.
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
The second set of plenary sessions at the Annual Meeting was intended to challenge participants and to provoke discussion of a plan for the future. The academic challenge may be framed as an issue of professionalism addressed to faculty members in their roles as educators and as health care professionals. Presenters were asked to rise to Dr. Shapiro's bait and "move towards the edge." Of particular importance is the need to capture the opportunity offered by advances in information technology.
The following text provides excerpts from the plenary reports with an emphasis on recommended actions. A more complete version is available on audiotape.
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Undergraduate medical education in an increasingly informed society
While there is a more informed society around us, physicians should not relinquish the role of medical decision-maker. It is time to think about continuing education as the prerogative not just of an elite but of society as a whole. Academic medical educators have a responsibility to ensure that societal needs for health education are met. Communications must be improved and the need for critical appraisal skills must be recognized in a society where such abilities may proveas important as in the professional world.
The infrastructure of medical education requires thought. More emphasis should be placed on the continuum from undergraduate to continuing medical education. Continuing education should emphasize the broad determinants of health rather than medical matters exclusively, and continuing medical education should be recognized as sustaining the profession. This will require more adaptable and responsive infrastructure.
As efforts are made to achieve integration across the educational spectrum, interdisciplinary realities should be recognized. Problem-based learning may present a means of drawing health care professions together. It is important to emphasize the development of skills for lifelong learning and to build the capacity for lifelong learning into admission requirements for health care professions.
Successful initiatives (e.g., CanMeds, Educating Future Physicians for Ontario) are already under way. The key to all efforts will be improved communication at every level.
It was suggested that faculty development may be the key element in improving integration of professional education programs meshed with the evolving needs of society. The faculty development program should be sensitive and sensible. It should address the underlying issues of recognition and reward for faculty and should emphasize mentoring in the broadest sense. Orientation and recruitment are the beginnings of faculty development. The challenge was put to faculty leadership to recognize the development process as central to almost any initiative in educational reform.
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Opportunities presented in medical education by tele-technology and informatics
The group discussing these issues came to consensus on a basic premise, "that informatics has an important role as one component in the teaching of medicine to undergraduate and postgraduate medical students, practising physicians, and patients." There was further agreement on a basic goal of establishing collaboration and cooperation among the various medical faculties, to include diverse disciplines within each faculty and to extend the resulting initiatives to embrace expertise found elsewhere on the university campus and within industry.
An initial recommendation was made to establish a consortium of all Canadian medical schools, specifically mandated to collaborate on the planning and development of infrastructure and electronic teaching materials. Sharing must be the operative word in the process. Such a consortium should work closely with the Royal College of Physicians and Surgeons of Canada, the College of Family Physicians of Canada, the Medical Council of Canada, and a number of other bodies with similar involvements.
A second recommendation called for a written policy paper to map out a strategic plan for the coordination of these activities. Such a plan should encompass education, research and critical appraisal.
The recommendations were based on a number of principles:
- Appropriate information should be available to the appropriate people in the appropriate place and time. This will require consideration of optimal information storage, packaging and dissemination.
- There is a need for a process to encourage official endorsement of information. This may require centralized management and wide consultation. Every effort should be made to avoid having 2 or 3 groups working in parallel, while leaving many issues unattended.
- Student and faculty development is important. Academic institutions have a responsibility to ensure that both faculty and students will be able to use information systems and recognize them as a key to continuous lifelong learning.
- There will be a need for a comprehensive policy on ownership of information, especially where it concerns the products of the proposed consortium.
- A clear plan will be needed for assembly of the tools with the necessary resources. Resources must be developed to match the identified needs.
- Activities of the academic centres in information technology must be accompanied by a very active research component. It is important to evaluate the success or failure of informatics initiatives in education.
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Health care: societal change and informatics
The third plenary group concluded that there was a major communications gap between the academic health science centre and the changing society it serves. It was felt that society does not fully understand the role of the academic centre and that responses from academia have been inadequate. Academic centres have been generally mute in their own defence.
A second theme from this group concerned the place of primary care. Primary care was taken as being broader than family practice but certainly including that role. Primary care has the potential to be the strongest link between the academic health science centre and society, but academics have not placed enough emphasis on this domain.
The third theme addressed concerned technology as a potential enabling tool. A concern highlighted was that increased use of various technologies, including information technology, could diminish, rather than enhance, communication with society.
There was also a feeling that the leadership in medical education lacks representation from those who influence public policy. Given the potential of initiatives in that arena to forge links between the academic centre and the community, more activity would be desirable.
The academic health science centre must be challenged to refine its vision of its own role while improving relationships with other components of the health care system and the community at large. Communication technology, carefully used, will be a tool for achieving this kind of collaboration in order to create a better health care system. The process must be one of continuous evolution based on learning.
Three specific actions were suggested for consideration by the Association of Canadian Medical Colleges (ACMC), the Association of Canadian Teaching Hospitals (ACTH) and the Canadian Association for Medical Education (CAME).
- We must acknowledge that there is a very wide gap between the academic health science centre and society. This gap must be recognized if it is to be bridged.
- Others must be brought into the discussion. Too often the academic science centres are talking only to themselves. Future discussions of reform in medical education should include social scientists, politicians, trustees, students, consumers, citizens, patients and other caregivers.
- Academic health science centres or, perhaps more accurately, academic health science networks, should seek a role as active participants in the evolution of the health care system, in discussions of governance, in evaluation of new service delivery methods, in examining the appropriate application of information technology, in setting the supporting research agenda, etc.
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Health research and educational change
The final group reporting to the plenary session looked at research and brought together questions concerning informatics research, as well as research on societal change.
A first recommendation called for the ACMC and the ACTH to advocate increased research funding. There is an urgent need for research funding be returned at least to the levels of the past decade. Ideally, funding should be increased to a level comparable with the level in other developed countries. To achieve this, there must be some system of ranking, to deal with the requests from special interest groups and to create a process for handling new research issues such as those arising from the Human Genome Project.
It is a matter of urgent priority that the academic centres learn how to achieve a balance between biomedical, health services and clinical research. Many feel that basic biomedical research is now desperately underfunded because it has been losing ground to health services and clinical research. The academic centres must put together a better marketing plan that will convince the political leadership that health research in all 3 domains is a good investment. It was recommended that government be approached for increased funding because deficits are dropping and because Canada's international position in health-related research is slipping because of funding cuts.
There are vehicles for influencing government funding. The Coalition for Biomedical and Health Research (CBHR) has been effective, but the ACMC is only one part of that voice, so the opinion of academic centres is diluted. It was emphasized that increased input from primary health care and family practice would be desirable. Initiatives through this channel would probably have a broader influence than those too closely associated with tertiary health care.
There was some discussion about the need for ACMC to have a separate and distinct research policy feeding into CBHR. The consensus was that ACMC would be well served by aligning itself with the strategic plan of the Medical Research Council of Canada, while working closely with other funding councils. It would certainly be undesirable to compete with other research agencies, since raising the profile for all basic research is desirable.
There is an urgent need for more effective lobbying of government for increased research funding. It was suggested that a public forum on health should be established, with a focus on biomedical research. The academic community must be seen to be reacting to societal change and societal expectations in health care. This long-term strategy would position the ACMC, ACTH and CAME to influence public judgement of research priorities.
No specific recommendations were made concerning health research in relation to medical informatics, although it was acknowledged that this is a critical area for academic concern. There are major initiatives in health informatics under way in Alberta, Manitoba and Nova Scotia, and virtually all provinces are showing an interest in this activity. The federal budget of February 1997 created the Canadian Innovation Foundation, with a mandate to support major initiatives in information technology, among other priorities. It is clear that academic centres must move quickly or be relegated to the sidelines in this critical area of health research.
Conclusion
No clear single direction emerged from the plenary discussions concerning actions to be taken by academic centres; however, there was a strong consensus that leadership is required from the ACMC and other national organizations with shared interests. There was a strong feeling that greater effort must be made by academic centres to understand the societal changes driving health care reform. One common theme emerging from the discussions was the need for stronger research at the interface between sociobehavioural and health sciences, including an emphasis on the study of communications and how new information technologies may best be used to improve the linkage between the academic health science centre and the community.
A sample of questions from the floor is presented in summary as an indicator of the richness of the discussion that followed plenary presentations.
Lorne Tyrell: One of the things we need to see is how technology is being evaluated within the faculties. I don't think this issue has been addressed. I'd be interested to know how other faculties review electronic publishing, especially with regard to peer review. We understand how to evaluate peer-reviewed publications because of the fact that they are peer reviewed. Furthermore, the quality of each journal is well recognized and its individual scientific impact known. We do have, however, some problems with electronic publishing. How do other faculties handle publications of that type at faculty evaluation time?
David Fleiszer: I cannot answer that question directly but it is an important issue. Initiatives using information technology should be subject to very close scrutiny. Is this a good way to do things? Are the effects using the technology positive within the learning process? It is important to put up a catalogue of people's experience. What is their experience with other ways of doing things? With other resource materials? It should be possible to get some good critiques collected from across the country so that institutions will not have to do all of those evaluations individually.
Abraham Fuks: I wonder if there is a specific and concrete recommendation on the necessary lobbying efforts. I do know that the lobbying effort over the last year, this spring in particular, did have an impact on the government's decision to go forward with the Canadian Foundation for Innovation. The work done by the Association of Universities and Colleges of Canada and others did have impact on that proposal. CBHR was very intimately involved in that lobbying effort, as were a number of the neuroscientists and members of the Networks of Excellence across the country. It is the first time of which I am aware that a lobbying effort in Canada has borne some concrete results. The fact that we also want the Medical Research Council of Canada budget to go up is another issue. In Montreal, we approached a number of ministers and senators and members of parliament to whom we had access, and I know a number of groups across the country did the same. It worked. I think that we do need some organizational structure in which to continue our interactions with government. They also should hear now that we were pleased that they responded. We need to say "thank you" and we need to continue our efforts to say, "and now we need the following." We don't need another council or committee but we do need some kind of structure or process through which to bring other interested groups into lobbying activity.
Brian Hennen: I agree that we don't need another committee. We have appropriate committees within the CAME and the ACMC. A coalition will require resources, and among the most precious resources are time and personal effort. Surely, the idea of a coalition and its goals could be built into some collaboration among CAME, ACMC and ACTH.
Clément Gauthier: During the fall and spring campaign to which Dr. Fuks referred, we did indeed collaborate with the Council on Health Research of Canada which is actually made up of the National Cancer Institute of Canada, 5 or 6 research institutes and the Canadian Cancer Society. They represent disease specific societies and lay persons actually benefitting from health care research and from the health care system. We did collaborate very closely. We provided them with the background information they needed. We are planning further collaboration, and I would emphasize that there is no need to reinvent the wheel.
With respect to other disciplines, the CBHR is also a member in a broader consortium of research formally known as the National Consortium of Scientific and Investigational Societies. It represents all disciplines, including biomedical researchers and social scientists. They have worked closely with ACMC, as has CBHR, in getting pharmaceutical companies to sign an advertisement in the Globe and Mail in support of the National Centres of Excellence and of the granting councils.
Jean Gray: I would not want to minimize in any way the importance of the federal government and the Medical Research Council of Canada to the research endeavours of this country, but I am a little concerned that we hear no mention at all of some of the provincial efforts. More important, from my perspective, the voluntary health agencies such as the Heart and Stroke Foundation of Canada, the National Cancer Institute of Canada, and the Arthritis Society are also being ignored. They are very important players in this whole operation. They are, at least in some regions, having difficulty with fundraising now. and I don't see us even talking about how we could help them with some of these endeavours.
John Ruedy: I'd like to pick up on Jean's comment because I sense an increasing malaise in the health charities. Not only are these organizations discouraged by the numbers of competing health charities seeking the same dollar, but they also sense that they are being ignored by the academic community and by other funders of health research. I think that this represents another opportunity for our organizations. If, in fact, we communicate and we interact and work with the health charities toward the same goal -- and they do have the same goal -- then they shouldn't feel that they are unimportant players.
