BUILDING A BETTER DOCTOR
Thirty-three years ago, upstart McMaster University in Hamilton sparked a revolution in the training of doctors that eventually spread to all the big medical schools in North America. Now it wants to start another. Its plan is bold, courageous and designed to combat some of the ills of today's health-care system. But will it build a better doctor? That debate is underway.
Since arriving at McMaster’s med school in September, Andrew Stewart has set a broken bone, put a tube down a patients throat, sutured cuts and drained pus from a knee and an abscess in the chest. Just 23 and full of spunk and the awe that comes with the responsibility of being a healer, even he is taken aback at all that he has done. Mac is famous for dunking its young undergrads into the real world as quickly as possible. Most schools allow their students only limited contact with real patients until they’ve had a couple of years of classroom training and simulation—usually with actors playing sick people—to their credit. But Stewart is one to drink deeply from McMaster’s well of opportunity.
With a mentoring physician not far away, he has worked in ERs in three cities in southern Ontario, in a pediatric ward and in an operating theatre as a student anesthesiologist, fitting those placements in around classes and seminars. “I haven’t done an arterial line yet,” he says, referring to running a tube into the byways of the heart. But that should come soon, and already he feels he is learning some of the
mysteries of the craft, like when to be direct and when to be vague. “Most patients are pretty good,” he says. “They joke, ‘Oh, let the kid do it, he needs the practice.’ But some don’t want me coming near them at all. It’s all about comfort level.” Comfort level being that often intimidating first rung on the way to becoming a doctor.
For a host of reasons—tight money, technological change, physician burnout— Canada’s 16 medical schools are, very cautiously in most instances, casting about for new ways to build a better doctor. Earlyyear courses in ethics, environmental health and alternative medicines are creeping into curriculums. As are increasingly dense courses on statistical analysis so future physicians can separate the vogue from the substance of new discoveries.
At the University of Toronto, Canada’s largest med school, first-year students are now required to tour that city’s many alternative clinics and homeless shelters, and to research in detail the health issues they find there. Toronto, Montreal and Vancouver provide rich multicultural environments for aspiring doctors to hone their listening techniques. “McMaster has everything you could want right here,” says second-year student Menaka Pai, 22,
referring to Hamilton’s four big acute-care hospitals and the latest in innovation. But for med students, she says, “there is still a hierarchy and you’re like a mini, less-informed resident waiting your turn.” And for medical training, all those glitteringly high-tech facilities are a seductive lure that keeps too many graduates—including Pai, the way she is leaning now—glued to the big cities.
Can technology also reverse that pull? At the University of British Columbia, surgical innovator Dr. Karim Qayumi and his son Tarique, a computer whiz, have developed a program they call cyberPatient that will soon be implemented at UBC. It allows fledgling surgeons and GPs to test their skills over the Internet—from wherever they are—on digitized patients as if playing a computer game. Harvard’s medical school is also investing heavily in virtual instruction in order to do more training outside its Ivy League base. Computerized training allows students to experiment with increasingly complex cases and alternative courses of treatment—and, in the Qayumi program, to calculate the medical costs involved at each stage.
THE PROBLEM with medical schools ‘is that we are empire builders. I want to break that model down.’
-McMaster health sciences dean Dr. John Kelton
“Nothing replaces real experience and real tissue,” says the senior Qayumi. An extraordinary man, he was a chief of surgery in Kabul who doctored in the mountains of Afghanistan when the Soviets invaded 20 years ago, training others with the crudest of equipment. That experience lends extra meaning when he says, “I’d rather have young surgeons kill hundreds of imaginary cyberpatients than harm a real person.”
Cost-saving, of course, is at the root of many of these innovations: med schools were forced to cut back significantly a decade ago and even today are producing fewer doctors—nearly a third fewer if you count the total as a percentage of the population—than they were in the 1980s. Also driving change is the fresh challenge of pushing new doctors out to the small communities where they are so desperately needed.
But alongside these imperatives are competing visions of what the doctor of the future should be. Should she—women be-
ing the majority in most medical schools now—be even more of an all-knowing superdoc than in the past? Possibly. Given the frenetic pace of discovery, “tomorrow’s doctor is going to have to be both a geneticist and more of an ethicist than ever before,” says Carol Herbert, dean of medicine at London’s University of Western Ontario, in an almost wearied tone. “Also a health-care economist in a way my generation didn’t have to be.”
Or is there a somewhat more prosaic alternative? A doctor who is more team player than all-purpose healer? Someone who brings merely one set of, admittedly well-honed, skills to the table? This is also part of the McMaster vision: it is the only med school in the country where training in nursing, midwifery, medical rehab and doctoring all exist under the same roof. But that element is only part of the revolution Mac is hoping to launch.
The problem with medical schools, says McMaster’s new health sciences dean, Dr. John Kelton, “is that we are empire builders. I want to break that model down.” Model-breaking having a place of honour in the McMaster tradition. In 1969, its founding faculty threw off the
old ways—students sitting for hours in crowded lecture halls learning anatomy and the history of disease. (“It was soul-destroying,” says the 53-year-old Kelton, an accomplished hematologist. “I hated it when I was in med school at Western.”) In its place, Mac developed one of the truly new innovations of modern medical training—what’s called problem-based learning: students, in small groups, presented with increasingly complex sets of symptoms and case histories and forced to work backwards to figure out what is wrong.
Today, at least 200 med schools have adopted the PBL approach. Most, however, still hew to the classical structure: two years of lectures, spliced with PBL seminars, followed by two continuous years of practical, clinical training in prescribed areas. Mac and Calgary offer a three-year, round-thecalendar program which, when you account for summers off elsewhere, is about six months shorter than the standard. Then comes residency which can last from two
to five years, depending on the speciality
When Harvard switched to PBL in 1985, it was front-page news. Other big schools followed, including U of T in 1992. Tellingly, perhaps, Harvard went to Mac to study its technique while U of T took its cues from what Harvard was doing. Who makes the better doctors in this country has always been something of a sibling rivalry. It may even be getting more intense.
This summer eight new students will begin their McMaster training in small hospitals and clinics in Sudbury and Thunder Bay, far from the health-care meccas of southern Ontario. They will do most of their training there, returning to Hamilton for a few weeks at a time for upgrading or specialized courses (you might not need this in your practice but here’s what a big stroke unit does) rather than the other way around. Kelton expects that in three or four years nearly every student who comes to Mac—138 are expected this fall—will be dispersed after a month or so of orientation to smaller centres around the province, possibly across the country. He has put a planned expansion of McMaster s medical library on hold so he can build instead the electronic umbilical cords to tie together a far-flung diaspora of med students. He envisions maybe 100 digital campuses in small hospitals, speciality clinics and family doctors’ offices where students and their mentors can quick-connect to the mother ship for seminars, upgrades or the latest innovation.
Part of this vision, of course, is the overdue recognition that the big city hospitals, the doctor-factories at the hub of the modern medical school, are no longer the allpurpose training grounds for young physicians. Advancing techniques and outpatient treatment have made them repositories for the sickest and quirkiest of cases, not the ones most doctors experience in regular practice. Kelton calls his plan “a marketplace model”—matching training more closely to the real needs of communities and ordinary doctoring. It’s also a leap of faith. Will it make for a better doctor? He’s pretty' sure it will. But he’s more confident it will make for a better health-care system.
The Canadian Medical Association has been estimating for years now that med schools are graduating 500 fewer doctors than are needed and that the shortfall is felt primarily outside the big centres. Mac’s plan is to build on the fearlessness of its Andrew
Stewarts and Menaka Pais and move the bulk of its mainstream training into smaller communities, with the hope that more doctors will discover professional and personal opportunities out there. Modelled in pan on a well-regarded system at the University of Washington, which has trained doctors in rural settings in Washington, Idaho, Montana, Wyoming and Alaska for decades, the idea is picking up endorsements from the province. Ottawa is also sniffing around, but especially interested are the regional health-system administrators who like the idea of gening ’em young.
Call it hormonal recruitment. This is a recipe for luring legions of twentysome-
The doctors of tomorrow, according to an Internet survey of first-year students:
51% are female
32% are from a visible minority-a greater proportion than the population as a whole, although blacks and natives are under-represented 69% of their fathers and
49% of their mothers are professionals or high-level managers
16% are from families with a physician parent
Source: Canadian Medical Association Journal
thing achievers in prime mating period to places where they may just put down roots. An added bonus is that small-town doctors not only get a student to help with their practice, they also get instant access to the latest in medical thinking—a natural and ongoing upgrading of their professional abilities.
“No one forces you to go to Fergus” or any other small town in Ontario, says Pai, who grew up in the small community of Dundas, near Hamilton, and has used her time at Mac to sample the high-tech wares in Boston and London, Ont. But those who do, she and others say, find themselves in tremendous demand. In the smaller communities it is not uncommon for lowly med students to assist in minor surgeries and even manage certain cases on their own. “I have friends at U of T and it is definitely very different,” says Pai. “They have their cadaver in four months and that is what they are dissecting. And that’s the big emphasis in first year.”
With a science degree in hand, Pai didn’t want to sit through more years of lectures. “Sometimes you worry that you haven’t learned everything you need to,”
says Pai, who is planning on a career as a cancer specialist. “But it really does seem to come together. And there is this tremendous sense of human contact.”
Contact versus content. That’s the balance med schools have been trying to get right for generations. It does seem to be shifting—in large measure because students are demanding more variety and more direct experience. At Western, populist alternative medicine is creeping into the course work because student groups have taken it upon themselves to invite guest speakers to campus, dean Herbert says candidly. At U of T, a group of early-year students is spearheading a drive to create a student-run community clinic to escape the ivory tower and “rediscover that feeling that drew us here in the first place,” says first-year med student Colm Murphy. “To get out there and help people.”
Murphy, a 27-year-old with an engineering degree under his belt, was accepted at both McMaster and U of T and was initially intrigued by Mac’s more freewheeling style. But some doctors he knew convinced him he would get more “theoretical depth” at Toronto. First-year U of T is heavily lecture-based and test-happy, Murphy allows. “But it is really forcing me to learn what’s in my books.” Will he remember it all in five or six years? “No, definitely not,” he shoots back. “But I’ve got to feel it’s created some sort of map in my brain.” Configuring that professional map in the brain is what these latest attempts to build a better doctor are all about. The medical landscape is changing so dramatically—constant discovery, patients showing up with their own Internet-collected health data and seeing themselves as medical equals—that only those physicians who have been taught how to learn, and how to find the time to learn, will do well.
McMaster feels it has the recipe: its ingrained PBL system of constant evaluation that can only be enhanced—hard-wired even—by students and their mentors learning at a distance from the specialized centres. “McMaster teaches you how to learn and how to manage your time,” says Brynlea Barbeau, 31, who graduates this spring and tested the system by taking a year off in the middle of her studies to give birth. “We evaluate everything to death— even the physicans we are assigned to.” The more traditional schools feel they offer that lifelong base by embedding the science, and reinforcing it at strategic
‘I’D RATHER have young surgeons kill hundreds of imaginary cyberpatients than harm a real person.’
-UBC surgical innovator Dr. Karim Qayumi
points in the training. So far, at least, the jury’s out. “There have been lots of studies comparing the two systems,” says McMaster’s Geoff Norman, a professor of biostatistics. “All they really show is that truly bright students can overcome any teaching regime you throw at them.”
Medical schools are a bit like ocean liners, says UBC’s medical dean, Dr. John Cairns. “We’re very proud, tremendously concerned about quality. And we don’t change direction easily.” That said, UBC is turning Mac’s way, just not quite as aggressively. Building partner campuses in Victoria and Prince George, UBC is also developing plans to train more of its students directly in small communities, at least in their middle years. To achieve this, it is investing heavily in virtual training and a telehealth network that will beam out, among other things, the latest surgical techniques from a state-of-the-art operating theatre at Vancouver General Hospital.
Other schools are sure to follow suit. A year ago, some of the top medical school administrators in the United States met at Harvard for a Think Big exercise in how to train 21st-century practitioners. Their suggestions in a nutshell: get students out of the big-city hospitals and into the places where real medicine is practised; move the patient-intensive years (the clinical clerkships, they are called) forward into early training; and concentrate the heavy-duty science in the first year and then again in the last when it can be hammered home on the heels of practical experience.
To help drive home all the doctor-making lessons a med school offers, U of T is even considering reintroducing what was once the grand underpinning of its entire curriculum, the history of medicine, to graduating fourth-year students. “We want them to learn from the profession as a whole,” says associate dean Richard Frecker, “so as not to repeat the mistakes of the past. ”
In medicine, however, the past can be a cruel instructor. Medical training is an arduous ordeal—students and interns still spend long overnight hours “on call” as did generations before them. Change comes when an institution with a flair for innovation, like McMaster, pops its head up above the crowd. Or when patients insist, in ever greater numbers, on being treated as equals in decision-making. Or sometimes it just tiptoes in the side door.
Neety Panu, 25, writes her final exams this month at Uof T before becoming an intern in neurosurgery in Saskatoon. This is just another step in her dream one day to bring those talents back to her hometown ofThunder Bay. For her first elective she went home to test the facilities, to see if there was enough opportunity there for someone with her ambitions. Convinced there was, or at least will be someday soon, she devoted the rest of her training to soaking up all the big-city techniques she could, along with a summer stint in rural India “to go back,” she says, “to medicine’s roots.” One foot forward, one back. That may be the 2,400-year history of western medicine. Revolutions have been sparked with a lot less. E3