SpankyMcFarland

I’ve lead that to others to judge. Last night on CBC it was the crisis for paramedics in Ottawa and the shortage of nurses in Ontario. Clearly you disagree with my perspective, so set out what you think and what you propose. Do you really believe the situation fine and dandy? Do you talk to foreign doctors and listen to their perspective on licensure? In my own long experience of recruiting specialist physicians, there was virtually no correlation between licensure eligibility and clinical competence. We missed out on a lot of excellent people.

The lesson is that large corporations should think long and hard before investing in a place like Florida under present management.

Many stations in my province have been staffed by nurses for decades so I am well aware of that. The point is that this doctorless state is coming for many more communities, bigger ones, if current trends are not interrupted. All I can tell you is that the efforts by govt in my province are failing, and well publicized initiatives don’t change that underlying trajectory. In my town a generation of locally trained GPs is disappearing and is being replaced by a smaller and more transient cohort, mainly of IMGs. We have attracted very few Canadian grads in recent years. The general news on the availability of GPs in Canada is also bleak. What should be done about all that? Should nothing more be done? BTW an assignment in medical school where one works with a team is better termed an elective rather than an internship to avoid confusion with the traditional post-graduate training year after medical school.

I m not advocating forcing anybody anywhere. I believe in attraction, not coercion. We have a problem getting medical care in many parts of this country. How to sort this out? 1. Continue to encourage Canadian doctors to work where they are most needed. 2. Bring in more FMGs. There are lots of exceptionally good ones out there. 3. Radically improve communication links between urban centres and universities to remote locations so that more care can be conducted remotely. Telemedicine is already working to some extent, e.g. in cancer care. 4. Expand the use of other staff e.g. nurse practitioners, nurses, physician assistants, midwives to fill in as much as possible. 5. Expand private care. 6. Admit failure and have the decency to warn the public they will no longer have adequate medical care in their communities. Encourage resettlement. I think a combination of (3) and (4) will be the main way my province goes. (5) may happen when we run completely out of options. Unfortunately as regards (6), being honest with people doesn’t come naturally to politicians. One other issue that should be addressed - the cost of medical school training. Much of the curriculum could be taught more cheaply online. That would leave students with lighter debts afterwards.

In a publicly funded system, where doctors want to work can be influenced by many factors, including compensation and conditions of service. Do we want every Canadian-trained doctor in the country staying in large urban centres like Toronto or Vancouver? Imagine if we ran other public services like that. Canada has sleepwalked into a situation where too many of its young graduates are staying in urban centres. It’s an awkward topic but we need to talk about the long-term implications of this and what we should do about it. Another major issue is call flight - young Canadian doctors who used to shoulder more than their share of call now insist on doing as little as possible of it. Work-life balance, restrictions on the licensing of foreign doctors and love of the big city mean we need far more graduates than we used to have just to stay where we were but that is not happening. If we are going to do nothing, let’s at least be honest with the rural part of the country about what they face.

Now, now, let’s keep it civil, shall we? Bill Gates has changed the world. Very, very few doctors or medical scientists can say that, maybe a guy like Charnley who invented hip replacements, the vaccine makers and a few of the drug developers. The message from innovative industries is as follows: judge peoples on their skills, not on courses they took thirty years ago. Canada is a very sparsely populated country. There is no reason why one college couldn’t operate here. We claim to have one standard of care - let’s make it happen like our national legislation on the matter sets out. What do you mean when you say ‘medical associations’? I think you mean the licensing bodies, e.g. CPSO, not the medical associations like the OMA which are basically unions? I am primarily criticizing the licensing bodies (although the medical associations are part of the problem). They have become hamstrung in a typically Canadian way by bureaucracy and need reform. I have written at length here about what I think should happen. Do you think there is a problem with recruitment of doctors in rural Canada and what would you do about it? And what do you say to the millions of people in this country without a GP?

In terms of recruitment of CMGs I would like to see substantial tax-efficient sums offered after, say, five and ten years of service in a remote location, perhaps a lump sum similar to the income earned, along with university appointments. I’ve seen both success and failure in such sites, often depending on the retention of one charismatic individual. My local university preaches the importance of rural medicine but very few of the preachers work in a remote rural site themselves. That has to change. Every year the head of the med school should be asked to publicly discuss a written audit on recruitment and retention of CMGs in rural sites, whether it has gone up or down in the last year, and what is being done to make things better.

I did compare Bill Gates and his ilk to doctors because people need to think about medicine differently. The old ideas are not fit for purpose. The medical field of knowledge is constantly changing and doctors need to relearn their profession on multiple occasions through their careers which is why ancient details of med school training have become a way of excluding experienced specialty physicians for no good reason. Now, there does have to be a basic floor of knowledge that all doctors have to reach - which is a different situation from IT - but the emphasis in both fields needs to be on up-to-the-minute expertise and comparing like with like, e.g. how much psychiatry expertise does a Canadian orthopaedic surgeon with twenty years of practice actually have? Not much in my experience nor should they and that should be the standard expected of foreign orthopods too. BTW why should your daughter have to go through this silly bureaucratic exercise of relicensing on multiple occasions to practice medicine in a country with only 35 million people? If we truly believe in one standard of medical care in Canada for all it’s a clear waste of resources. For foreign grads it is even worse - a purgatorial repetition of document exchange from med school onwards each time another license is asked for. The Original Sin of a foreign medical degree is never forgiven. I have no desire to bring doctors into Canada who are of a lower standard than the doctors here and there is no need to do so if we actually spent the resources to test such applicants rigorously. Don’t profile doctors by their country of origin - examine their skills individually. Yes, India and Pakistan have some terrible medical schools but because of the numbers involved those countries also produce people who are at least as good as anybody in Canada. Some of those brilliant people might work here if we made it attractive for them to apply. We need them urgently.

Well, you have more than papers (and ‘papers’ are part of the problem - I hope this is changing but in my experience email was used less than it should have been to authenticate licensure in Canada instead of ye olde documents couriered endlessly back and forth). As in any other industry, you have the individual too, an individual who is not necessarily limited by the medical training they received. Imagine if Silicon Valley subjected every applicant to this malarkey instead of finding out what they could actually do? Mr. Gates, I see you dropped out of Harvard without a degree…Why not subject that person to a truly rigorous set of examinations and practical assessment that they assist in financing? It doesn’t matter what an eye surgeon studied or didn’t study twenty years ago if they are fully competent today in their scope of practice. Test that scope. Focus on the present and the future as regards skills. With all that said, there is one major aspect to be looked at in the past of any applicant - evidence of incompetence or behaviour that is unethical or downright illegal. That area should be better done than it is now and nobody would object there. The thing is that the licensing authorities are only responsible for the doctors who are licensed here. Who is responsible for the people who quietly die prematurely at home because they didn’t have access to medical care? Somebody has to be accountable for them too.

I don’t see what’s wrong with that. No, standards are not simple at all. How much clinical medicine should a 50 year old pathologist be expected to know, somebody who’s been in their specialty for 20 years? Should they be expected know more about the management of bipolar disorder than their Canadian peers in lab medicine who are practicing away perfectly competently? What is the point of querying the training they had in their internship 25 years ago? There are hundreds of examples I could quote you on this. What about time away from clinical medicine? Should a person applying for a pathology residency, somebody who has had a brilliant career in basic science and surgery, be subject to the same requirement for time out of practice as the average young applicant who has no expertise? I could create standards so tough that nobody would pass. Would that be a good idea? You’re not going to test a fighter pilot on his knowledge of quantum physics. Standards have to be relevant to the ever-changing skills required for the job. Another aspect of this is the obsession in Canada with the details of medical school training, often decades ago. Good med students and doctors, like good businessmen, writers or scientists, aren’t limited by the teachers they have. Test their skills, not their courses. The four to five years of training you are referring to is called a residency. Internships are usually one year long after medical school and have now been merged with residency training in Canada, which is another mistake this country has made. Doctors who have done their residency training in the UK or Ireland have frequently trained for far longer than 4 years. If they are surgeons or obstetricians they would have performed surgeries on their own that few Canadian residents would have had a chance to do. In addition, the training programs are often discontinuous, meaning that a surgical trainee who gets into trouble will have a hard time finding a new job. Not ideal for patients perhaps but good for us here if we want to pick up people who are far more ready to work in an isolated centre than the average Canadian grad fresh out of a highly supervised five year residency. We have had many superb surgeons and anesthetists, mainly from South Asia, who did long stints in Britain before coming to North America. They are as good as experienced Canadian physicians but many would not be eligible for the Canadian exams because of the way their training is assessed. A colleague of mine with 8 years of residency training in the British Isles after internship, who was a lecturer in cardiology in a British university and had a fully independent internal medicine practice in Canada, was adjudged to have six months of Canadian-type training and was obliged to do 3.5 years of a Canadian residency before he could sit his exams here. An utter waste of time and money.

Poilievre needs to forget about crypto and convoys and focus on the problems of the country - health care, the telecom stranglehold of Rogers and Bell, affordable housing, military procurement, protecting the Arctic, China. If he came up with suggestions that have eluded successive PMs for many years, I would be willing to listen.

I don’t know where you’re getting the idea I would require lower standards in remote locations. The opposite is the case as physicians are often on their own out there, esp. at night. This is why it’s doubly wrong to send foreign doctors to remote locations for their first jobs in Canada. Their sole focus is then on escape and the churn of doctors just keeps on going. Standards are not a simple matter at all. As I explained already, requirements can be so arduous - and take so long to get through - that they can deter good candidates and leave only the people who have no other options. Not every new requirement increases medical competence. Canada also needs to radically increase the training posts for foreign docs. There’s no point telling somebody they need to do another year of training when it’s not available. I am not trying to force anybody to do anything so let’s forget that. And please don’t call incentives ‘bribes’. There is nothing illegal about them. What I am trying to explain to you is that the incentives so far offered have clearly been not enough.

My FP’s secretary responds to recorded queries only until 1 pm. There’s no other way of contacting the doctor. It’s like something from the Seventies. At the golf course I can book my game weeks in advance online but not at the medical clinic. It is surely not beyond the wit of man to code patients so that complex cases are not booked in beside each other? In addition, I have to wait for my 2pm appointment until he’s ready to see me because he’s backed up. There’s no reason why I couldn’t get a message on my phone telling he’s an hour behind and to come at 3 instead. Every medical clinic should have nurses assisting the doctors, fielding queries and offering detailed advice after the doctor leaves. There are so many bloody obvious improvements that could be made without even having to think about it. No doctor has asked to see my Fitbit recordings which show all sorts of interesting things going back years regarding exercise, heart rate and sleep. Medicine is naturally conservative - innovation has to be tested to ensure no catastrophic errors may come with it - but there is going to be more pressure for health care to catch up with the result of the world on IT. My province had an information system from the last century that was recently hacked with chaos resulting afterwards. A few IT people I know criticized some of the basic security measures taken that were not really up to snuff.

It might be a start. There is a groupthink at work among these bodies. The same individuals frequently move from one to the other. With some notable exceptions, they are not really interested in making incentives work in the periphery sufficient to move doctors there. No public goals for rural recruitment are published and followed. There’s no accountability by anybody in the system, from the Minister down, for failing to replace rural FPs. We had a med school Dean who was appointed for his expertise in rural medicine. Once he was in the job we never saw him again. He didn’t visit the rural sites. Our licensing bodies have no need to consider the real world effect of their crazy rules on medical recruitment. They plough away happily in a vacuum. Many of their number come from the local med school where is there is a natural scepticism of foreign doctors and a bias in favour of restricting medical manpower supply. There is a profound conflict in Canadian medicine about rural medicine. On the surface, everybody emphasizes the importance of rural health care. If you were to listen to applicants to med school or prospective medical residents, you’d think that many couldn’t wait to get out to the boonies. (Academic physicians talk in the same way.) But that doesn’t happen when they are qualified and nobody has really investigated this mystery with a cold and courageous eye. My solutions are many. Let’s start by getting rid of the ‘force’ canard - none of that will be used. Get serious about bonuses for the periphery that are actually big enough to interest people in moving and creating community teams big enough to be sustainable. At the moment, the medical associations are dominated by people who live in larger centres. How keen do you think they really are to give the most peripheral doctors massive bonuses and better call schedules, especially when those people are often foreign doctors? Conversation about where doctors work in Canada. In my province c. 80% of the physicians in towns under 10,000 people are foreign. Nobody is talking about being forced anywhere. I am not building a gulag here. Canadian doctors need to have sufficient incentives to work in towns under 10,000 people. In addition, we also need more foreign docs, nurse practitioners and telemedicine. Private medicine will have to be expanded as well.

Canadians need a reality check about medical sociology. The centres of medical power in each province - medical schools, licensing authorities, medical associations, departments of health, public payers of physicians - tend to be concentrated in large centres, often quite close to each other, and share a set of values no matter what is said to the contrary. So it is that everyone in the citadel, from the lowliest applicant to med school to the Minister herself, knows the importance of talking fulsomely about the vital importance of rural medicine before returning to their city homes at the end of the day…and fully intending to keep it that way. Our two medical solitudes in Canada are urban and outback; it’s about time we started an honest conversation between them.