Medicine—Beyond hope?

The expansion of BC’s medical program is the first in a series of steps we must take to deal with the current health care crisis in the province. Physician retention, particularly in the North, and an imbalance in the number of specialists and generalists remain problems in need of action.

About this article

”Medicine—Beyond hope?” was first presented by Dr Snadden as the inaugural Bob Ewart Memorial Lecture in October 2004 in Prince George.

Dr Bob Ewert was born in Prince George in 1927 and graduated from the Prince George Junior/Senior High School. Following studies at UBC and McGill Universities and surgical training in Detroit, Dr Ewert returned to Prince George in 1961 as the city’s first consultant specialist. Dr Ewert was a dedicated surgeon with strong ties to the community and a vision for a modern, well-equipped hospital with a full complement of specialists. His roots in the community and commitment to the development of medical services in the North stemmed from his father, Dr Carl Ewert, who arrived in Prince George on a paddle wheeler in 1913. He came in response to the physician shortage in Prince George and the surrounding area at that time, and practised as a general practitioner in Prince George until his retirement. Bob Ewert remained in Prince George until his death in 2002 at the age of 74. Bob’s family, many of whom are still in the Prince George area, made a generous donation to the University of Northern British Columbia to dedicate and furnish the Bob Ewert lounge, which has become a revered space for students and staff working in the new medical building. The Northern Medical Society created the annual Bob Ewart Memorial Lecture in celebration of the birth of the Northern Medical Program at the University of Northern British Columbia.

History of the Northern Medical Program

In June 2000, approximately 7000 residents of northern BC came together at an arena in Prince George to protest their region’s health care crisis. Physician shortages had led to a physician strike. Leading policymakers, community leaders, academics, and physicians were at the rally and a call to train “physicians in the north for the north” followed. The rally focused on discussions between the University of Northern British Columbia and the University of British Columbia Faculty of Medicine about the feasibility of medical training in northern BC. Six months later, an agreement was made to create a distributed model of medical education with the University of Victoria as a third partner. Provincial funding followed and the aim was to double the number of places for medical undergraduates in BC by 2010. In the distributed model all students would be UBC students, follow the UBC curriculum, and graduate with UBC degrees.

In the next 2 years, buildings were planned, staff were appointed, and students were selected who would be appropriate for training in the North. In the summer of 2003, the ground was broken at UNBC for the Donald Rix Northern Health Science Centre. In spring 2004, testing of technology and accreditation took place and the building opened on 17 August 2004. The first students were admitted to the program on 30 August 2004.

Increasing physicians in BC—are the numbers correct?

Until 2003, UBC admitted 128 students per year. In 2004, the number increased to 200, with 24 places in the new Northern Medical Program, 24 in the new Island Medical Program, and 24 more added to the existing program. An intake of 256 is anticipated by the end of the decade.

To meet its needs, Canada requires approximately 2500 new physicians a year yet graduates only about 1500.[1] BC’s estimated need is 300 new physicians per year, yet only approximately 75 UBC graduates remain in the province annually. To extrapolate from these numbers, approximately 150 of 256 graduate physicians per year may stay in the province. Even after the medical program expansion, BC could face a gap of 150 physicians per year unless we find a way of convincing more of them to stay in the province. Demographic changes and the long overdue feminization of the physician workforce[2] mean the shortage could be greater. So BC may still face a shortage of physicians that requires continued reliance on what seems to be a dwindling pool of international medical graduates.

Health issues in northern BC

Northern BC (for simplicity, the Northern Health Authority area) has poorer health outcomes than BC as a whole. Northerners live, on average, 4 years less than everyone else in BC. They have, for example, higher death rates from lung cancer, diabetes, motor vehicle accidents, and alcohol-related conditions.[3] Most of these problems are preventable. Mental health admission rates, rates of chlamydia infection, domestic violence, teen pregnancy, and child abuse or neglect are all higher than the BC average.[4] These conditions are related to the socially determined illness one finds in populations that are marginalized or experiencing relative poverty.[5] These figures suggest that the difference in health status between northern BC and the rest of the province may be related to socioeconomic differences.

Issues in medical education

If we are facing a shortage of physicians and problems that are preventable or related to socioeconomic factors, are we training the right kind of physicians? White’s classic 1961 study on the ecology of medical care included some interesting data on where medical students receive their clinical experience.[6] This study was repeated by Green in 2001 with similar results.[7] In Green’s study, of 1000 members of the population over a 1-month period, 217 visited a physician, 65 visited a complementary or alternative practitioner, 21 visited a hospital outpatient clinic, 14 received health care at home, 13 visited an emergency department, 8 were admitted to a general hospital, and 1 was hospitalized in a university teaching hospital. It is in university teaching hospitals that students have traditionally been taught—akin to learning forestry in the sawmill. Are modern university hospitals, with their emphasis on ultraspecialization, the right places for students to be exposed to the breadth of disciplines?

Descartes’ legacy

To try and make some sense of the dominance of ultraspecialism and a disease-curing research agenda in modern medicine, we need to go back to René Descartes. Descartes, a 17th century French philosopher, is credited with developing a philosophy that set the foundation for modern science. He described the need for an objective science and promoted the concept of dualism—where the mind and body were seen as independent entities.[8] From this arose the belief that experiments that discovered how parts of the body worked could only be determined through objective experimentation and that this objective evidence was independent of the mind. This has led to the rigor of objective experimentation in science and the development of reductionism, where we examine things in smaller and smaller detail in an attempt to develop a universal understanding. In medicine we are dominated by scientific thinking, often to the exclusion of the individual experiences of our patients. We are driven by guidelines based on best evidence, and the gold standard is the randomized controlled trial that attempts to control for everything except the variable under question. Most research money goes toward understanding humans at the molecular level and developing treatments and cures often at the same level. This has led to huge advances in our abilities to understand and to treat disease. For all practising physicians, however, who live in the messy and confusing world of human experience, there is often a mismatch between what works in a controlled setting and what works for an individual patient. We can’t deny the impact of technology and our scientific understanding in helping stamp out disease, but we can question whether we sufficiently consider the impact of a person and their context on an illness and recovery from it. Engel summarizes this, “since science begins with accurate observation, scientific medical practice must begin with an accurate and thorough history. But the patient will, as a rule, provide a detailed, thoughtful, and accurate history only when the physician enters into an open, interested, and facilitative relationship with the patient. That sort of communication becomes a critical scientific tool, without which medical work could proceed no further.”[9] This need is well recognized in the development of person-centred medicine.[10] Canada leads that movement, but it does not appear to be embraced in all disciplines of medicine and is not yet at the core of most medical schools. One challenge in educating the next generation of students then is to balance Descartes’ legacy of reliance on objective science and increasing reductionism with attempts to ensure students have greater understanding of the limits of medical science and the impact of illness on individuals. For this they need to develop attributes like empathy and social responsibility. Problem-based learning[11] and efforts to control the content of curricula to levels that students can manage[12] are tactics that have been employed to achieve this.

Perhaps the biggest casualty of Descartes’ legacy has been generalism. As a basic definition, generalists are not only family physicians but also hospital specialist physicians with a broad or general practice—not the sort of person whom major teaching hospitals seem to value or train or that specialty training programs appear to support, yet arguably the very sort of physician that northern and rural areas need. Medical literature has been asking questions about the demise of generalism for many years[13-15] and recent authors have asked whether modern medicine needs to have generalism enshrined as central to its activities.[16-22]

If what the population of northern BC needs in terms of helping the burden of illness and the types of doctors it needs is generalists in the broadest sense of the word, can we meet the needs of the population with a medical education system that appears geared up to promote specialism? Most medical workforce planning in westernized nations aims for a workforce that is a 50/50 balance between family physicians and specialist physicians. Workforce planning in health care is an inexact science, so this is a pragmatic rule of thumb. In BC 40% of graduates are matched to family medicine programs and this is the general aim across Canada, though the rate varies somewhat. Family medicine has the biggest vacancy rate in the CaRMS match. Why is family medicine no longer a first choice career? Students seem to be discouraged from entering a discipline that is disregarded or downplayed as a career choice by many of the specialist physicians they meet in their clerkships. Even some family physicians, demoralized by the current situation, discourage students from entering family medicine. The huge disparity in income and the large debt load of graduates are other important factors. Similarly, why are some specialty areas difficult to fill in the North, particularly the “less popular” specialties such as psychiatry and geriatrics, some of the most in-demand services due to the increasing age of the population and the increasing demand for mental health services? Are they not attractive as specialties to work in? Are they tarred as low-status jobs to students tramping the corridors of elite specialist units? Are they underrepresented in medical education curricula?

The reasons for the situation we face are unclear, but they pose a problem if medicine is to develop a true social responsibility to meet the needs of the population, particularly the northern population of BC. Elitism may exist within medicine, but should not do so at the expense of the broad physician base required to deliver the majority of health care. We need to show students examples of expert generalists at work. Many students think or are led to believe that expertise and specialism go hand-in-hand and that generalists are, by definition, not experts, whereas, in effect, true generalists may have just as great a body of professional expertise as a world-renowned specialist. The current imbalance between the number of generalists and specialists in BC needs to be addressed.

The future of medical education in BC

In BC we are fortunate that physicians, communities, government, and universities have recognized that many of these issues are in need of action. The Faculty of Medicine at UBC has taken the huge step of developing a socially responsible revision of its medical education program through the development of the distributed medical education model. In the North this will allow us to teach where the patients are—in the communities. It will give students frequent access to generalists as well as to ultraspecialists, for both are equally important to the future of medicine.

So today, at the start of the Northern Medical Program, we have enthusiastic and skilled physicians, superb support from all our partners and communities, an innovative Faculty of Medicine, and a great group of students. We are well placed to fulfill our mission of training “physicians in the north, for the north” and to focus on rural, remote, and aboriginal health issues.

Acknowledgments
I would like to thank Dr Wayne Weston, professor of family medicine in the Faculty of Medicine at the University of Western Ontario for his help with the manuscript. I would also like to thank Dr Gordon Page, director of the Division of Educational Support and Development and professor in the Department of Medicine at the University of British Columbia for his helpful comments, and the Northern Medical Society for the synopsis of Bob Ewert’s life.

References

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David Snadden, MBChB, MClSc, MD, FRCGP, FRCP(Edin)

Dr Snadden is associate vice president of medicine, a professor in, and associate dean of, the Northern Medical Program at the University of Northern British Columbia, and an affiliate professor in the Department of Family Practice at the University of British Columbia.