More health specialists not the answer to health system woes
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
It was only a decade ago that headlines in Canada were filledwith pessimism about the nation’s critical doctor shortage. Waittimes for specialists were increasing, doctors were leaving for theU.S. and patients couldn’t find a family doctor. Yet a recent studyfrom the Royal College of Physicians and Surgeons of Canadanotes that today, one in six new health specialists cannot findwork.Surely, this must be disheartening for recent graduates, who,after 10 to 14 years of post-secondary education, areunderemployed and saddled with huge debt loads.Can we at least take solace in the fact that our health system hasimproved 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 tospecialists remains a huge barrier. A quick check of the Ontario government’s website, for example, shows that waittimes for orthopedic surgery is 261 days in Thunder Bay, compared to about 110 days in Toronto. We have moredoctors, 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 biggestfactor 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 improvequality of health care.The problem, however, is that most quality defects are not due to lack of provider skill, but to poorly organized patientflow, poor communication and poor teamwork. One in fifty patients in hospital is harmed unnecessarily due to thecare they receive. Best practices
such as ensuring the right drug or test is done at precisely the right time
don’thappen about half of the time.These quality problems exist not because doctors are not well trained, but because health care has become socomplex. 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 andprompts, 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 apremium. Medicine will soon face a wave of disruptive technologies driven by genetics, consumer-accessible devicesand micro-implants. Already, heart surgeons face tough job prospects because better cardiac stents have reducedthe 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 electrocardiograor ultrasound. While such devices will never eliminate the need for specialists, they may dramatically change whichspecialists are needed and how specialists are used.