The Death And Life Of Canadian Medicine, Part Iii

You can't create a job description without an understanding of the modern job demands.

Previously in this series: Part I, Part II

We're constantly made witnesses to breakthroughs in medical science, and how we train doctors is always in evolution. Still, rarely do we think about what we need and want in our doctors from the standpoint of the patient. I don't mean at the individual level - doctors by and large serve their patients to the limits of their knowledge and then some. And I don't even mean at the community level, whether local, provincial, or national. Though we desperately need a properly functioning physician job market in Canada, the allocation of residency spots somewhat approximates those needs, or at least used to.

Instead, I mean taking a hard look at what practicing medicine actually entails these days, and rethinking what we need and want in doctors as a consequence.

Prior to World War II, most of the contact between doctor and patient would have been episodic, to diagnose the patient's condition and treat however possible. Much of the time, the condition was either cured or self-limited. In other instances, cure or surgical attempt at cure was not possible, and the patient died. Whether the remedy was empirically proven or quackery, it had been this way since Hippocrates.

Medicine has changed radically since the postwar period, and of course living standards have improved dramatically with better housing and sanitation. That means medicine (or at least non-surgical medicine) has become much less about cure, and much more about applying science and its fruits to keep people alive and reasonably well far longer than could have been imagined even a century ago. Joint replacement, dialysis, organ transplantation, mass-produced insulin, and almost every medication used to treat chronic disease didn't exist before World War II. It's a testament to the explosive growth in medical knowledge of the past 50-75 years.

But progress has created something medicine could not have foreseen, namely a segment of the population living - and often languishing - with multiple chronic diseases. This kind of patient isn't all that new - one thinks of the elderly "GOMERs" from Samuel Shem's 1978 House of God - but has become a growing conundrum for medical education and medical practice.

These are stories we're all familiar with: elderly couples dangerously co-dependent for their basic everyday living; dialysis patients with amputated limbs; and seniors with bad hearts and bad lungs, in and out of hospital despite intensive multidisciplinary care. And almost all will be cared for by several medical specialists with expertise in a single body system or procedure, taking well upwards of a half-dozen medications. The catch, though, is that the studies that drive practice guidelines generally exclude patients this sick or this complicated. With the sickest patients, doctors are (perversely) often in uncharted waters.

The usual answer to the dilema of multiple chronic disease is that we need more "generalists", particularly family doctors. After all, who better embodies the vision of the patient as whole person? Who better to act as both gatekeeper and quarterback (if you can pardon the mixed metaphor), and recognize what the patient's real needs are, than a doctor with a broad base of knowledge and skills? And what's more valuable than the long-term patient relationship and community focus that lie at the heart of Family Medicine to best exemplify this "generalist" approach?

Maybe.

Yes, Canadian family doctors receive an outstanding broad-based medical education. They are trained to build and value long-term relationships with their patients. And these days all med school applicants have to show some sort of initiative towards improving life in the community.

But the delicate balancing act of managing multiple chronic diseases, and comfort with practicing in the absence of good evidence - on frail seniors no less - only come with experience. I didn't gain this kind of comfort until I'd been in practice for years, and some otherwise excellent doctors never get there.

The management of frail and complex patients is still new to medicine, and quite alien to most of the profession's traditions. It's much more art than science, demanding unique cognitive skills and interpersonal instincts. It's not a guarantee that medical pelatihan instills them in our doctors, if that's even possible.

It might be that to bring about the legions of "generalists" our system needs will not only require a new approach to medical training. It might also require a new ideal student of medicine.

Next time: the educational life cycle of medical students

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Ditulis Unknown — Tuesday, May 8, 2018 — Add Comment — Canada, doctors, education, Family Medicine, generalism, geriatrics, health policy, medical education, primary care, Royal College, specialization