Dear colleagues,
We’re part of an evolution that is probably going to have as dramatic an effect on how we practice medicine as the introduction of antiseptics or antibiotics.
You’ve probably noticed that our role as physicians has been evolving over time. The Royal College is addressing this in educational development by transforming physician training to a competency-based approach, improving our residency accreditation processes, and determining a new approach to continuing professional development.
The digital revolution is really spurring these changes. We’re moving to a system which clearly has more technical support and capabilities in order to come up with diagnoses. There are also more diagnostic categories, staging of diseases, molecular signatures and explanations for disease to grapple with. At the same time, almost in reaction to this technology, there seems to be a growing hunger for the humane physician.
Patients are seeking physicians who are professional, good at communicating (both speaking and listening) and capable advocates, all within a setting that is digitized — driven by guidelines and evidence, on very short timelines. This is going to be a challenge for us all. We will have to wait and see the actual impacts the distribution of time, effort and technology is going to have on how we are physicians; but, I’m watching these changes closely and with interest.
The Royal College is part of a group at the Canadian Medical Forum (i.e. leaders in Canada’s major, national medical organizations) who has been studying “The evolving role of physicians and the medical profession.” This project is endeavoring to present a vision for the “physician of the future” in Canada, based on the current and forecasted state of our health care system.
The draft results of this project’s multi-phase survey of Canadian physicians, other health care professionals and patients; combined with a review of recent research and reports on physicians’ roles; was just shared with the project partners. I would be happy to share more details on these findings and proposed next steps, once a final report is available.
In the meantime, I’m curious; what’s the biggest change you’ve noticed in your practice from when you started in medicine until now?
Sincerely,
Andrew Padmos, BA, MD, FRCPC, FACP
Chief Executive Officer
February 23, 2017 at 11:20 am
I want to make the comment regarding the CanMEDS consortium.
It is all very nice and productive to join forces in standardizing the education and the testing. How about the testing regarding new immigrant physicians into Canada?
Are we at the stage of one test for proficiency that is applied and valid for all of Canada? or does the individual have to prove his or her proficiency in each province still before being granted permission to practice in that particular province?
I would love to know if that is presently occurring or a pipe dream still.
March 2, 2017 at 10:51 am
Hi Alex, thank you for your comment. The Royal College does manage a number of routes for international medical graduates to be assessed against Canadian standards, depending on their medical training background. Having said that, each individual province still has its own jurisdiction over who they will license and the criteria for such. Standardization of those processes would have to be initiated from the provincial colleges.
Sincerely,
–Andrew
March 2, 2017 at 11:10 am
Thank you Andrew, for your response. I would like to suggest that as a primordial offshoot of CanMeds, and your present official position, you could start the process to lead the Provincial Colleges in a move to standardize their criteria for licensing physicians throughout Canada.
This movement, even if it takes long, would leave a firm legacy for all time of your efforts and that of the Royal College in assuring standardization of human resources for all physicians, Canadian graduates and foreign.
Alex
February 11, 2017 at 9:11 pm
Look it up.
I graduated in 1989 and practice as a general internist. When I was a resident, battered copies of Harrison’s Principles of Internal Medicine in the ED medicine room were for reference. Charts came up, by the kilo. Journals were photocopied. The number one thing I do now that I did not do then is look things up and I look an awful lot of things up. I saw one patient with syncope and antecedent neuralgia in the neck and face. Google the terms neuralgia and syncope and see what you get. That is what she had. I recently saw a patient with a million dollar workup for possible knee sepsis who was on broad spectrum antibiotics but also suffering from gout. Could this be polyarticular gout masquerading as sepsis? Yes says google at least to proof of concept and the patient gets immediately better on steroids. Except I am doing the looking up, not the residents I work with. Why is that I wonder? They want to be told, and think it is a fault not to know.
The problem is exasperated by our testing system that is outdated and artificial. Data is now readily accessible yet we test our medical students, residents and fellowship candidates on knowledge retrieval tasks that are best left to silicon based data storage systems while other essential aspects of medical care such as diagnostic reasoning and concpetual thinking, areas that contribute to adverse outcomes, are left to chance. I routinely ask about NNT. Nobody knows, nobody cares. DVT prophylaxis, practically a religious conviction, has not been clearly shown to reduce mortality for medical inpatients and despite residents zealously ordering it almost none know anything about the evidence supporting its use. Patient with hypernatremia are almost treated without bothering to do free water deficit calculations, resulting in a delay to correction. Does this patient have lupus? Start with a google search for the criteria.
And when it comes time to review medical inpatients, failing to take a full and accurate history is problem number one. Next in line is failing to review all of the relevant investigations readily available on the computer based system.
The answer is out there. We need to teach people to embrace ignorance and humility and ask a lot of questions. And look it up. Grey matter is outdated. Lets embrace the age of silicon.
March 2, 2017 at 10:57 am
Hi Stephen – nice to hear from you. I applaud your candor. While I wouldn’t go so far as to agree that “grey matter is outdated” I do support your call to embrace technology as a complement to other clinical skills and knowledge. Asking questions and investigating (e.g. through research, patient histories, etc.) will always be essential components of being an effective physician. Innovations should permeate all aspects of training and practice – including, retrieval and investigative skills (computer-based and otherwise). I’m trying to follow your guidance in my small hematology practice in Windsor, N.S. -Andrew
February 9, 2017 at 11:11 am
Agree completely with the overwhelming majority of comments. It’s what happens when politicians, rather than health professionals, are left to run health care systems based upon a 1950’s (Tommy Douglas) dream of health care funded only by taxes. Politicians only care about what happens in the next 4 years, not what happens over a person’s lifetime. Advances in medicine and technology, not even dreamed of decades ago, allow medical miracles but cost more than any totally tax-funded system could possibly afford. Hence, denigration of physicians to reduce their remuneration, (already ridiculously low compared to strongly unionized and comparatively (certainly to physicians) unregulated occupations such as teachers and police – who ever heard of a teacher or police officer working into their 70’s?), rationing of services and now in Ontario, violation of patient privacy rights. As long as the public believe the nonsense propaganda espoused by politicians, the health care system will continue to deteriorate.
March 2, 2017 at 10:57 am
You point out some valid challenges vis-à-vis long and short-term goals. For any health care system to be effective, sustainability must be a foundational consideration – especially with the dawn of (expensive) technology, changing patient/public expectations and increased patient volume and complexity. As some of your colleagues have pointed out, our health care system has gone through radical transitions before. It will take time and leadership for improvements to take effect. There will be no easy solutions. -Andrew
February 9, 2017 at 11:06 am
We certainly live in interesting times. The Jan 14th edition of the Economist had a great editorial as well as supplement on ongoing learning and education. It has great relevance for our profession.
I think what it points out is the challenges and what I would even say – the failure of many CME – Departments to prepare for and deliver what is needed for all physicians to be able to respond to this increasing and pertinent needs of our patients.
I would wonder if this should be a measure of within educational assessment.
March 2, 2017 at 10:59 am
Hi Brian, I’m intrigued. I will be sure to look up this editorial and supplement. –Andrew
February 9, 2017 at 7:25 am
I am of the same vintage as Dr. Padmos, in fact we did some medicine rotations together in the 1970s. I have come to Hong Kong to private practice in 1992. What I have read in the many comments have been creeping into medical practice here in Hong Kong too. And this happened mostly within the last decade or so, after the hospital administrators( MBAs in Health Care or PhDs in Nursing who couldn’t or wouldn’t know how to change a dressing, but they sure know how to have meeting after meeting). At public hospitals electronic health records(EHRs) made the interns and residents, and frontline nurses spend more time looking at the screen rather than listen to what the patients or their relatives are saying. Forget about detailed clinical examination, that’s for the exams only, it;s scan this and scan that. I have witnessed a nurse did not have one second of eye contact when a family member of an elderly patient who was asking her for some information (the doctors were too busy to speak with the relatives) abut their loved ones. All full 5 minutes she was typing away or writing up her chart. Until the family member finally yelled at her to see if she’s been listening! Things are far better in private hospitals because the patient/the family is paying the nursing staff’s salary as well as keeping the hospital in operation. I will never want to go to a public government hospital in Hong Kong, unless you know the consultant or Chief of Service looking after you.
I just wonder how retiring colleagues are faring in Canada with regard to their health care. At least here in HK I have private practice colleagues to choose from, as I have kept paying health care insurance at a very high premium to get coverage in private hospitals etc to the tune of USD$1.2M annually, and I did not have to wait to have a colonoscopy, cataract extraction nor an MRI scan–all paid for from my insurance.
March 2, 2017 at 11:04 am
Peter – good to hear from you! I’m glad things are going well for you in Hong Kong. The challenges we’re facing here in Canada are well-documented and not dissimilar to challenges in other health systems. For example, wait times, administrative and patient volume, unintended consequences of technological solutions, etc. We’re all looking for effective and sustainable solutions. I’m a big fan of learning from and with others. -Andrew
February 8, 2017 at 8:58 pm
As a retired physician who graduated nearly 52 years ago I have noticed a marked change in physical diagnosis skills among those currently in medical school and those who trained especially since the advent of the i-pad and i-phone. Their skills in physical diagnosis are poor. I recently had the opportunity(?) to teach a resident in Internal Medicine doing an elective rotation with one of my physicians how to conduct a peripheral neurological examination. I am on a medication which can cause peripheral neuropathy as a side effect over time. This specialty resident had no good idea how to examine a patient for proprioception. Young physicians seem more attuned to making and investigating suspected or possible diagnoses based upon what their mini computers say about clinical practice guidelines rather than using good clinical skills to narrow down the possibilities. Why learn how to examine a patient properly when you can order a whole pile of lab tests or just book them on the long waiting lists for CT scans or MRIs? Another pet peeve is that many young physicians listen to patient heart sounds and lungs through the patient’s clothing! Who teaches them that? In my day my teachers would have failed any student or PG trainee who ever did that on a regular basis!
March 2, 2017 at 11:07 am
Smartphones and tablets can be great resources when complementing proper physical examinations and patient histories, certainly not supplanting them! I’m displeased to hear of their misuse. We will continue to champion the training of well-rounded and skilled physicians, as well as support initiatives like Choosing Wisely Canada that seek to reduce the wasteful ordering of extraneous tests/prescriptions. -Andrew
February 8, 2017 at 6:46 pm
The biggest change I have observed in the practice of anesthesiology since I entered our discipline, was the leap from ‘rag and bottle’ practice to a quantum leap in technology, leading to a significant improvement in patient care. In the 1960s the only monitors that were available to us were vital sign monitoring such as “finger on the pulse”, manual blood pressure monitoring and visual observation of respiration. As a trainee I was aware of pulse oximetry and end tidal CO2 monitoring but never thought we would see that type of monitoring in our life time because of cost. Then there was a sudden ‘fast forward’ in the progress of Anesthesiology. Monitoring became a key component of the practice of anesthesia. Continuous ECG monitoring became a requirement. Automatic blood pressure devices were introduced and direct blood pressure monitoring, using arterial catheters, became routine for the more difficult cases. End tidal CO2 monitoring and pulse oximetry was required on every patient. We could measure the exact concentration of anesthetic in the brain. We could monitor how deeply patients were anesthetised. Guidelines to practice were introduced. We became the leaders of the Patient Safety Movement in Medicine.These changes all took place within the forty years or so that I practiced.
March 2, 2017 at 11:09 am
It’s incredible, the speed with which this all occurred! I’m sure you have some fascinating stories to tell. –Andrew
February 8, 2017 at 6:20 pm
Having graduated 54 years ago I have seen many changes:
MEDICARE – after some years in family practice before Medicare (and before I became a neurologist) I found this a huge improvement in the equality of care of my patients
MEDICAL EDUCATION – it has changed from lecture based, teacher oriented, to small group, learning based, student oriented,and patient and community focused.
ACUITY OF HOSPITAL PRACTICE – In the 1960’s the hospitals looked like Holiday Inns with an X-ray department, with many patients having prolonged rest and recuperation periods and long stays while tests were done sequentially. Now everyone is very sick and their stay is short.
RISE OF NON-PHYSICIAN ADMINISTRATION – While they brought great expertise, they also introduced a business model to medicine. We can debate the pros and cons, but it was a major change.
COMPLEXITY OF MEDICAL PRACTICE – While much of the complexity reflects advances in medicine, practice in the 1960s looked more like a Norman Rockwell painting. Now Rockwell would have difficulty trying to capture a portrait of the array of specialists, the technology, the daily electronic messages, flurry of guidelines, administrative edicts, medical politics, and physician oversight. Again there are pros and cons, but still a major change in my career.
WAITING LISTS – for much of my career I defended Medicare against the attackers, as my patients all seemed to benefit, and none were harmed. Then came the time when the waiting times for tests and care clearly were unacceptable and were harming some patients I still defended Medicare but recognize an urgent need for serious reform, and for true leadership in leading the change.
I applaud the College for looking to change in a proactive rather than a reactive approach. We want vision and leadership as we go forward. As we look back we can point to certain individuals like Tommy Douglas and Allan McEachen who initiated major health care change. Our current problem is not a lack of money, or a lack of physicians, but a lack of courageous leadership. If we want a better system for our patients, and to avoid the system falling to the medical entrepreneurs, we need to seek and support leadership.
March 2, 2017 at 11:12 am
Thanks, jock, for reading and commenting with your usual insights and historical perspective. You provide a wonderful summary of some of the major changes our system has seen. I appreciate you giving consideration to the pros/cons of all of these changes. As we know, Canada’s health care system is once again contending with challenges (some new and some recurrent). We recognize that we cannot solve these issues alone. The Royal College is working with partners in health care to influence positive changes within our sphere of influence. I sincerely hope we can provide some of that necessary vision and leadership, as we work with others for the betterment of the system. -Andrew
February 8, 2017 at 5:31 pm
After 47 years of practice I have recently been a patient with several major symptoms and diagnoses. I do understand the importance of “evidenced based medicine” and have been well cared for by a surgeon. But my GP’s lack of hands on care has left me feeling uncared for and abandoned. While the use of eyes and hands in the process of care may not be the ultimate diagnostic tool, it is the first line tool and is in my opinion the most important for the patient. As patients the “evidence” may leave many of us with inadequate investigations and treatments. However the loss of the feeling of being “cared for” is of equal if not greater concern.
March 2, 2017 at 11:13 am
I agree – the less tangible aspects of care are of utmost importance. (Please, also, accept my best wishes for your personal health and recovery). -Andrew
February 8, 2017 at 4:51 pm
The problem is the paradigm healthcare technology has. Doctors don’t need electronic medical records systems. The technology that is needed is automation, collaboration and communication tooling. Great record-keeping might help you be an incrementally better physician, but, exceptional communication between all members of the circle of care stands to impact the health of your patients far better than the digitization of your records. The evolution of billing tools, that became scheduling tools that had record keeping bolted onto them has resulted in a toolchain that causes the master to serve the tool. Something about a tail wagging the dog…
What we need is to re-frame the role that technology plays in the provision of healthcare to one that frees the circle of care to focus on communication, collaboration and care rather than data entry. This will require the creation of a new toolchain that the existing market players Infoway, Telus, QHR/Loblaws/Accuro, EPIC and Cerner are ill-equipped to produce. This will require a new kind of innovation that puts the health, happiness and productivity of its users above all else.
The question we need to ask ourselves is where is this innovation going to occur? Who is going to fund it? Groups of physicians banding together to produce a better solution? Will it be the CMA? The community has been burned by a multitude of software development mishaps — ehealth ontario, CMA’s investment in MDPS. The collective availability bias of the Ministry, Health Authorities and physician community makes the notion of investing in this kind of innovation unpalatable. I wish to assert, however, that unless the community comes together and creates an environment to foster this kind of innovation we will be using terrible software for decades to come.
Full disclosure I’m not a physician, but, married to one. I’ve built technology companies in the healthcare and finance industry.
The possibility of a delightful toolchain that frees the community from the tedium of EMR-purgatory exists.
March 2, 2017 at 11:17 am
Hi Ryan, you raise some important questions. I agree that technology-based solutions that free up physicians for better communication, collaboration, etc., are the ultimate goal. I’ve always believed that technology should complement and facilitate care, not be a burden or a crutch. Thank you for taking the time to comment. -Andrew
February 8, 2017 at 4:07 pm
I am retired from specialist practice and find I hear from non physicians ,what they find deficient and their comments support the opening comment from the CEO.We do seem for many reasons no doubt to be drifting away from much physical examination merely because we feel we know what we will find , while also not sitting for even a few minutes to listen. This leads to multiple consultations and visits. Technology is great for settling aspects of diagnosis but humanity is still required, in most cases for settling the anxieties and concerns. Even two minutes concentrated listening to the concern may be all it takes. Of course this may mean that in a day you will see one less new consult. Try to solve this without becoming deeply political. It is unprofessional and in the long run the public will see that if we do not ever get up at night; never listen, and never really examine; why bother ? Become a banker instead or an engineer they may think. It is tough doing the job well but that is where our place in society came from. –Only my opinion of course.
March 2, 2017 at 11:19 am
Hi Paul, thank you for your thoughtful comments. It’s true – being a physician is not for the faint-at-heart and does demand a lot from you (I’ve personally always believed the trade-off to be worth it). Thank you, also, for the reminder about the ever-important impact of active listening. –Andrew
February 8, 2017 at 4:04 pm
The creeping bureaucratic intrusion into medical practice. Having spent 17 years as a surgical chief (surgical program director/chief of Surgery; depending on the name of the day), I could see the ease of gaming the MOC system; and the ease with which those most in need of supervision gamed the system. There are statistics that show ‘average morbidity’, ‘volume of patients’, ‘average cost per patient observed over expected’ (from provincial health plans), and combined with the complication rates provide by hospital’s medical records…. it gives a much better indication of where competency efforts should be directed. This has not stopped (stupid) bureaucratic rules and directives and requirements to practice. Electronic records should (be able to) sell themselves on their benefits and not be a burden imposed by someone who thinks they are just so wonderful.
March 2, 2017 at 11:21 am
The best use of data and technology are when the outcomes enhance patient care. That is the kind of system and automation and requirements of practice that the Royal College will continue to champion. -Andrew
February 8, 2017 at 3:52 pm
The Royal college should enter the political fray in this time of expanding bureaucracy and physician vilification.
To quote Aristotle:
Man is by nature a social animal; an individual who is unsocial naturally and not accidentally is either beneath our notice or more than human. Society is something that precedes the individual. Anyone who either cannot lead the common life or is so self-sufficient as not to need to, and therefore does not partake of society, is either a beast or a god.
…in other words, the RC cannot sit back watching while its members continuously take it on the chin.
March 2, 2017 at 11:23 am
Hi Harvey, we work hard to support our Fellows within our mandate. Several years ago, we reached out to our members to help define our advocacy directive and were told by the majority that our role should be one of trusted steward – providing information and analysis. This year, as we prepare our next strategic plan, are keen to hear from our member about what is most important to them. -Andrew
February 8, 2017 at 3:43 pm
Suggested Reading From FORBES MAGAZINE
First, We Devalued Doctors; Now, Technology Struggles To Replace Them
http://www.forbes.com/sites/davidshaywitz/2015/10/31/first-we-devalued-doctors-now-technology-struggles-to-replace-them/#78c2430f3196
David Shaywitz ,
Contributor
March 2, 2017 at 11:25 am
A very thoughtful piece. -Andrew
February 8, 2017 at 3:42 pm
Electronic record keeping is hindering (standardizing) the human interaction between the doctor and the patient, and this standardized approach is forgetting the individual patient.
March 2, 2017 at 11:27 am
We must do what we can to preserve and champion the humane aspects of care. -Andrew
February 8, 2017 at 2:58 pm
The biggest change is the constantly increasing expectations for physicians (knowledge, accountability, time with patients, documentation standards…..) that are not supported or acknowledged. Despite the increased expectations people expect faster when in fact the standards demands slower. The system is designed to waste physician time and put excessive responsibility on doctors. The colleges don’t support doctors in advocating for remuneration, support and system changes to ensure better standards can be achieved and just dump responsibility on doctors. (ie hypocrisy). The colleges let physicians be given ridiculous responsibility (eg balance a hospital budget with government approved 2% Allied health wage increase but no hospital budget increase) with no power and don’t defend us against the governments doing so. The college increases the standard without ensuring means for physicians to follow them. Please put your neck on the line with the rest of us and activily get political. Get the provincial colleges together. Physicians work in a system, you can’t do your job without advancing system change as well. But you won’t. You will say it’s not your job or not your place…and physicians and patients will suffer….which is your job to prevent…..
And no EMR is not the easy answer to everything. It can slow down care as much as speed it up and you know that.
So what’s changed. I have to do more with less. Be responsible for things I can’t control. Simultaneously achieve conflicting goals. And no one is talking about this honestly and frankly. Which means there is no support. All in all, I’m set up for failure despite being dedicated, passionate and hardworking.
March 2, 2017 at 11:32 am
Hi Mark, it’s true that political advocacy is not within our mandate (nor our updated advocacy directive, as informed by our members several years ago). That said, I know that these issues are important to a lot of our members and for that reason are of particular importance to me. I would be happy to discuss with you how you think the College can best help. Please email me at ceo@royalcollege.ca and we can arrange a time of mutual convenience to discuss this at length. -Andrew
February 8, 2017 at 2:56 pm
The electronic medical record is really turning out to be a significant problem and already we see publications that residents and staff physicians are spending more time working on their computers and they are dealing with patients. Much of this is being driven by administrators with their own agendas under the guise of patient safety whereas in fact one could argue that patients are becoming less safe because physicians have less time to actually interact with them. As usual Canada seems to be 10 or 15 years behind the curve in that in places like the United States and Australia, they’re looking at scribes for data entry and as many physician helpers are as necessary such that the physician can concentrate on only the things they can do.
Most physicians are not later day Luddites and certainly the electronic technology-voice activation, large touchscreens that can show multiple record details, fast intuitive and interactive computers are available. However in my monolithic system in Alberta, many of the computers are still using XP which is an even supported anymore by Microsoft.
I can find and use details on a paper chart about 60% faster than with the current electronic record system and so inevitably I’m going to not be able to see as many patients or see them as effectively once this is fully implemented-try to explain this to your local administrator
so I would have to say the major disconcerting change that I’ve seen over the four years I’ve been in practice is not the increase in scientific knowledge or diagnostic procedures-it is this creeping medical bureaucracy with its own agenda which often is contrary to what might be best for the patients are patient care
March 2, 2017 at 11:35 am
Hi Malcolm, you are not the only one who holds this opinion. Obviously, balancing record-keeping needs with quality patient care is something our system will need to remedy in the years to come – especially as technology advances – and stagnates, in some cases. As we’re constantly reminded of, various technological systems in use can also pose challenges to unified solutions/new ways of doing things. I am always open to learning from others and am in discussion with partners in Australia and elsewhere in the world and welcome their contributions (advice, cautions) on this and other issues. -Andrew
February 8, 2017 at 2:37 pm
The biggest difference is the overabundance of Ob/Gyn’s leading in part to the reduced patient load and number of surgeries I do. The college’s role in rationing doctors or residency spots is not apparent to me.
March 2, 2017 at 11:37 am
Hi MS, you are correct that this work does not fall under the College’s mandate. We are, however, working to inform decision-makers through our initiatives to consolidate and provide data on the make-up of Canada’s medical workforce. http://www.royalcollege.ca/rcsite/health-policy/medical-workforce-knowledgebase-e -Andrew
February 8, 2017 at 2:28 pm
I graduated in 1974. Since then I have noticed more fragmentation in the care of the individual patient. Whereas the primary care physician looked after more aspects if not all in his/her patient, today more caregivers are involved. Care is more specialized, calling for more coordination, communication and accountability. This also raises several challenges, an important one being avoidance of duplication of services.
March 2, 2017 at 11:39 am
Hi Andreas, you are correct that further specialization does pose some challenges and we recognize this. For the past several years, we have been working to define and support generalism in medical education. If you’re interested in learning more about this work, please visit http://www.royalcollege.ca/rcsite/education-strategy-accreditation/innovations-development/initiatives/generalism-medical-education-e -Andrew