Thursday 15 March 2018

Medical School. Who should be in and who should be out? Are we makng the right choices?

      When I decided I wanted to become a doctor, life was a lot simpler.  First one had to pass the entrance examination to University.  If one couldn't manage that, that was the end of the  story.  As far as I can  recall one was permitted three tries and if one failed three times, that was the end.   You weren't getting into University at all, let alone into Medical  School.  No-one thought, in those days that everyone should go to university.   No one considered that it was unfair discrimination or racism that all potential candidates were not accepted.  In fact, it was widely recognized that an applicant required a certain initiative and level of competence to be a suitable candidate for a university education.  In those distant days, applicants or their families had to pay their fees, so even the candidates did not want to waste their time and money entering a program that they were likely to fail.  This tended to weed out those who were not likely to ultimately gain a degree that would be an asset to their success  in later life.
      Getting into medical school in those days did not mean you were going to come out a physician.  If one failed to meet the standard one might easily be thrown out!  There were other standards that had to be met, as well as mastering the core content of knowledge.   There were standards of professionalism demanded of a prospective physician.  If the academic faculty. the professors and the Dean of Medicine felt a candidate did not meet the required standards, unless the situation was remediable that candidate  would not allowed to continue the program.  Although the years have clouded my memory, I believe about twenty per cent of the class I started with in Medical School  fell by the wayside.   Any appeal would be dealt with in-house and if it failed, no lawyer would have been sufficiently presumptive to assume that he knew better than a committee of  professional peers whether a candidate was fit to become a physician or not.
     Things are quite different today, when short of criminal activity, no  matter how inadequately a candidate performs he/she is almost certain come out of the program with an MD degree.  The martinets of Academe dare not face the legal teams that will appear on their door-step to challenge their decisions.   As you may have already read in a previous blog, a failed resident is currently trying to establish a suit against Western University, (until recently the University of Western Ontario) for failing to pass the specialty fellowship examination.  Should he succeed the nature of medical education in Canada, and perhaps elsewhere, will be radically changed.   Since it is almost impossible to fail a candidate, the admission process is critical, because once admitted, short of illegal or immoral behaviour, almost everyone who gets into med school will come out as a qualified physician.  The old joke, Q. "what do  they call the person who graduates at the bottom of his medical school class?" A." Doctor!" isn't so funny anymore.
     The Universities, the licensing bodies, the doctor's union (the Canadian Medical Association) and virtually all of the medical associations are intimidated by the prospects of litigation, or falling foul of government and its legion of administridiots. There remains a method in addition to marks, to attempt to ensure that the quality of prospective physicians and other health care workers meet an acceptable standard.  That is by the selection requirements to get into medical school and even that is a target of the bureaucrats.   So, let us at least make it as relevant as possible.
     Not  all schools require a personal interview and other requirements, such as letters of reference and letters from the candidates vary considerably from school to school.  Aside from marks, some of the qualities are extremely difficult to assess even in a carefully planned interview and almost impossible without one.
    The academic knowledge component is the most easily examined and tends to be the most  emphasized, perhaps because it is so well documented and available.    While undeniably important, it is often over-emphasized. In many areas of medical  practice there are very important skills that are unrelated to high marks.  For many years I have maintained that a B+ student with the right qualities can make an A+ practitioner.
     The value of the interview is that it gives skilled interviewers an opportunity to observe the general  presentation of the candidate and his/her attitudes, aptitudes and aspirations.   Admission interviews are very labour intensive.   They require training of the interviewers and tie up four people per interview, and I suspect for that reason in many institutions much of this sort of information is gathered by references, letters or essays written by the candidate and/or referees.  Unfortunately, these are often more indicative of the candidates ability to hit on the 'right' formula and sometimes templates are easily recognizable in the letters submitted.
     In the interview, the demeanor and general presentation of the candidate tells a lot.  Anxiety is normal and we spent some time in making the applicant as comfortable as possible.  Some candidates were obviously well rounded, had broad interests in what is going on in the world and showed comprehension appropriate to their age and experience.  Some were totally lacking in general knowledge.   Some had never read a book. Some had a realistic idea of what it might be like to be a physician and had talked to a doctor or nurse or someone at their local hospital.  Some had aspirations and ambitions to do something in health care, like be a family  doctor or a pediatrician or a 'research' doctor.   Some had no such aspirations and one fellow answered my question re an important achievement with, "I'd like to get around the golf course in par."        
    There were four interviewers and while that may have been a bit  overwhelming, it made the procedure very fair, as each interviewer graded the candidate separately and only after the interview did we compare scores.   If ALL of the interviewers were not very close in their assessment, the candidate got another interview.   That did not happen very often. 
    I continue to believe that the interview is an important part, perhaps the most important part of selecting prospective physicians, who will deliver the best possible care to the population.   I hope it will not be abandoned in favour of easier but less valuable methods of selecting the future generation of physicians. 
If you have any opinions on this, share them with me!!

Monday 5 March 2018

Be your own Health Historian.

  Some time ago I blogged about the value of developing a systematic approach to keeping available your own personal health history, which should be in your possession and available at all times.   This applies to everyone but particularly to active senior citizens, who, like vintage automobiles may be functioning admirably most of the time, but on occasion require immediate attention to keep  running.  I addition, the tendency to forget issues you wanted to address or at least mention during the standard ten minute visit to your family physician is often forgotten in hustle and bustle of a busy office and the anxiety of the moment and needs to be to be added .
   Few people read my blog, (my kids assure me of this quite frequently), so it is particularly gratifying to me, when out of the blue, a friend or acquaintance mentions some aspect of my opinions or suggestions that they deem helpful to them in traversing the vicious medical jungle, that all but the political 'elites' encounter whenever health problems arise.
    Most recently, one of my friends casually mentioned a recent encounter with Health Care Ontario, when his health care interrogation was just beginning, he put his hand into his breast pocket and pulled out the carefully written history he had crafted in response to suggestions in a previous blog and said something to the effect,
    "you'll find it all here!"   
    My interpretation of what he told me was that they his interviewer re-acted with something akin to amazement and commented on the clear and concise history he had written.
   "Can I keep this,?" the astonished  doctor asked.
   "Of course," my friend said.
   " Where did this come from?" he asked .
   ( My friend smiled at me, "Of course, I got it from your blog.")
    "Oh, a friend of mine in the business recommended it as a way to ensure accuracy and save everyone's time."  he replied.
      I interrupted my friend to mention, " I always take three copies with me when I have an appointment for hospital consultations or investigations.  Because everyone I encounter on my way to treatment usually has to take the time to take a history.  I used to get tired repeating the story to the student, to the resident, to the staff physician and anyone else involved when I  was referred for investigations or consultation.
   'Can I keep this', is the question they most frequently ask, because it reduces their work load and everyone wants their work load reduced.  Additionally, they know there is no one more concerned than you, the patient regarding the accuracy of the information.  When I get to the resident or doctor who settles down in front of the computer, ready to start pounding out the necessary details before we can proceed, I present him/her with the documented history.   As a result, h/s can take their eyes off the computer and actually look at me.  Instead of interacting with the computer and trying to type everything into the record in the ten or fifteen  minutes available for our appointment the doctor actually has time to to establish eye contact and to talk to me."

   The sad truth is that even dedicated, caring family physicians have been bullied into practicing medicine based on a ten minute consultation fee.  If your physician spends much more time than that with  you he is subsidizing you and the bureaucracy  at his own expense.      Much of health care has gone the way of the house call. When the people decided that the doctor's home visit is worth much less than the plumbers visit, they sealed the fate of now almost defunct house call.  The miracle is that some physicians will still make house calls when they feel it is in the patient's best interest and if you look at the fee schedule you will realize that this is a charitable act by a caring physician.  So, bearing in mind that a ten minute visit is now the norm, anything that will focus that ten minutes into a therapeutic session is valuable.  The last thing a sick  patient requires is the physician wasting both their time filling in the boxes that the administridiots need to run the health care system as the Health Care Industry.  And that is what much of the interview has become, primarily concerned with collecting the business data instead of being solely focused on patient care.  The physician's forced occupation with the data being entered is not primarily concerned with patient care.   It is concerned with the business of the system, not of the patient.
   I was an early and enthusiastic proponent of the computerized medical record and its benefit to patients.  I introduced the computerized medical record to  the Department of Family Medicine at the Mt. Bridges Family Medicine Unit, the first EMR in the Western Family Medicine Clinics. I am disappointed with the current use of the EMR generally, because the administration has diverted the system from its vast potential as a health care tool, to use for their own benefit.   It has become a distraction from the very purpose it was created to address. 

   To get back to the point, you, the patient must do all in your power to re-direct your ten minute visit into a concentrated patient-physician interview.  Neither you, nor the physician, have time to waste. Not only do  you need a focused, concise history to present to the doctor you are seeing today, (who incidentally may not be the one you are familiar with), you also need to have pre-considered questions you may want answered and to write them down.  It's easy to forget things you wanted to address amidst one's anxieties in the hustle and bustle of a busy family physician clinic.
   Because we are so mobile these days I think a simple inexpensive project could improve health care significantly.  It is so simple and inexpensive and involves so little high tech expense that no one wants to be bothered with it, despite the fact that it may save more lives and money than high tech devices.   Everyone could carry their entire medical history on a card not much larger than one of the many credit cards that most of us carry in our wallets.
   So, in addition to  having your medical history available in a concise and easily accessible form on your person at all times, you need to have a list of the questions you need answered the next time you see your doctor.

If you are interested in learning more about this, or have ideas about how to achieve these objectives, let me know.