The first post in this series laid out the mendasar questions that need answering if Canada is to find a way forward in its quest to find the right mix of doctors working in the right places. Now it's time to look back at the decade when most of the mess was made, for reasons that range from simple demographics to deliberate (if poorly thought out) policy decisions.
A doctor who trained in the 1970s and early-to-mid 1980s would have finished medical school and a one-year hospital based internship to qualify for an independent license. Some of those graduates would do additional residency pembinaan to get certified by the College of Family Physicians of Canada (CFPC), others would simply begin independent practice as family doctors. Still others would enter Royal College specialty programs right away, and the last group of new doctors would work independently for a few years with a plan to specialize down the road.
In the late 1980s, a Canadian Medical Association task force found major problems with the quality and adequacy of general internships across the country. The CFPC flexed its muscle too, arguing that Family Medicine was not something a doctor could practice competently after one year of floating around a hospital. As a consequence of the ensuing debate, policymakers and medical schools did away with the rotating internship as a path to an independent license. Doctors practicing under the old post-internship system were grandfathered in, and medical students would now decide whether to train in Family Medicine or enter specialty pembinaan right away.
It's impossible to understate the effects of the policy shift. In fact, elimination of the rotating internship was the single most significant medical policy decision in Canada of the past thirty years:
- It removed hundreds, if not over 1000 new graduates from the pool of practicing doctors, by extending post-med school pembinaan to a minimum of two years. This, incidentally, was the major driver of the perceived family doctor shortage in the 2000s.
- It created the residency match system. This shifted the costs and stresses of career choice onto students with little experience on which to base the decision.
- It all but eliminated re-entry as a path to specialization (except under return-of-service agreements).
- Ironically, the shift probably fed the systemic disrespect for Family Medicine, rather than raise its profile. In the immediate term, Family Medicine became a mere "back-up" career choice for students wanting to specialize. In the longer term (i.e. the present), major segments of medical school would be taught by specialists with little insight into the realities of a community general practice.
No discussion of the 1990s is complete without addressing Toward Integrated Medical Resource Policies for Canada, more commonly known as the Barer-Stoddart report, but not for the reasons most people think. There is probably no document simultaneously more reviled and more misunderstood in health care. Yes, Barer-Stoddart is the document that infamously recommended Canada cut the size of its medical school enrollment. But it wasn't commissioned by an elected government to provide political cover for a radical change in policy. Rather, it was a set of recommendations prepared for Ministries of Health based on the major consensus problems in Canadian medicine at the time. The authors consulted with all the appropriate authorities, including doctors. If they reached the wrong conclusions, then a whole lot of people they interviewed were misinformed. As for the med school cutbacks, they were reversed and then some by the early 2000s.
The Barer-Stoddart report can be faulted in two ways, however. First, the authors were given neither the resources nor mandate to gain an accurate picture of the medical workforce. It was reckless to recommend Canada train fewer doctors without having a better feel for the impacts at the community level. And second, the authors didn't (or at least couldn't) fully appreciate the effects of medicine's changing demographics and practice patterns.
While the cliche of the Old Country Doctor is indeed a cliche, the doctor trained in the 1970s and 1980s was very likely a male that worked very long hours, regardless of specialty. The doctor trained in the 1990s was increasingly likely to be a woman, with male classmates ready to play a more active role in the household. Doctors worked fewer hours and saw fewer patients, a musim that would continue well into the 2010s.
Finally, nobody could foresee the impact that increased specialization and focused practices would have on Canada's doctor workforce. In some fields, like oncology, focusing on one or two aspects of practice makes sense. It's not possible to stay on top the latest therapies for more than a few broad types of cancer. Likewise, some surgeries are so technically difficult to master, expertise requires a highly focused practice. But beginning in the 1990s, and through to the present day, doctors found themselves able to limit their scope of activity, following their interests and fulfilling system needs. This doesn't mean the doctors were rushing into work solely for money, though that happened too. Rather, family doctors (and some specialists) found work as hospitalists, or in the ER, or addictions, or palliative care, or walk-in medicine, or any of a hundred other areas of medicine with a real need for help.
Given enough time, thought, and money, even these legacy issues from the 1990s can be addressed to the benefit of the Canadian public. What demands a mendasar shift in thinking isn't the changing nature of the doctor. Rather, it's the changing nature of the patient.
Next time: coping with chronic disease
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Sunday, May 6, 2018
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