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Targeting Societal Health Needs

May 8, 2012 by rcpsc

The challenge of fulfilling societal health needs is a multi-faceted issue, so what can be done to ensure that Canadians are receiving appropriate and well-targeted care?

Meeting societal health needs requires responsiveness to social determinants of health, which address the root cause of inequalities in health; however, calculating what needs exist is a multidimensional equation. Part of this issue is ensuring that the right mix of physicians with the correct skills sets are training and practicing in areas of need. Determining health human resource (HHR) occurs through the marrying of both quantitative and qualitative data to create a unified, well-founded picture of need.

Quantitative approaches look at the number and type of doctors being produced, a data set that represents collaborative responsibility of various levels of government, organized medicine and other health professions. Conversely, a qualitative approach addresses the types of knowledge and attitudes that equip practicing doctors to meet the health needs of the population they serve. And although HHR planning is imperfect, a further layer of complexity lies within unique issues with respect to HHR planning for each specialty, therefore demanding a coordinated, flexible approach to adequately address societal health needs.

That said, who is then responsible for determining this mix? Postgraduate medical education (PGME) is a major component in creating physicians who are prepared to respond and serve societal needs; thus, medical schools have a large responsibility in perceiving and reacting to the needs of society while also being accountable by consulting with the public about priorities and the impact of its needs. Yet, this approach can be disjointed and regionally focused. To entirely address the whole of Canadian health needs, an aligned effort amongst PGME, governments and bodies, like the Royal College, is essential in establishing a more coordinated, accountable system of HHR planning that incorporates both quantitative and qualitative approaches.

Considering the unpredictable nature of ever-evolving HHR needs highlights the necessity to prepare physicians to be more flexible and adaptable so that they are able to evolve over the course of their professional lives to meet societal needs. I encourage you to read the recommendations outlined in the Royal College White Paper on Societal Health, and urge you to post comments on the Royal College’s approach and strategy to bettering societal health in Canada.

Dr. Bob Maudsley, MD, FRCPC

Posted in Original Posts, Posts by Topic, Posts by Type, Societal Health | Leave a Comment »

Ensuring Patient Safety: A Way Forward?

March 9, 2012 by rcpsc

As a physician who has experienced the discomfort of sitting in a room amidst my peers having the details of how our care of a patient “went wrong”, Dr. Nakajima has raised a critical question. How do we reinforce our sense of professionalism and continual learning in a culture that historically has expected highly trained professionals to perform perfectly? The first consideration is to understand human factors, namely how highly skilled people perform in complex systems. Skilled humans do make mistakes at very predictable rates. Given a look-alike drug, every one of us has a 1 in 300 chance of administering the wrong one. Complex systems also generate errors as the care process involves dozens, if not hundreds, of steps. So understanding that human error is inevitable is important, so we can measure and mitigate it.

The second consideration is creating psychological safety, i.e. making it safe to learn. A simple algorithm that differentiates unsafe people from skilled individuals in unsafe systems is essential. You can’t be malicious, drunk or consciously taking on unacceptable risk. Additionally, we need to ask whether two or three people of similar skill and training could have made the mistake in similar circumstances. Having a simple set of rules is essential. Making them live and breathe can only occur when leaders consistently create psychological safety, so we can learn from errors and system flaws to keep everyone safe.

Michael Leonard, MD

Posted in Patient Safety, Posts by Topic, Response Posts, Uncategorized | Leave a Comment »

The Burden of Proof: A Lesson in Teaching the Just Culture of Patient Safety

February 8, 2012 by rcpsc

We have all been there, sitting in an auditorium, officially attending Morbidity & Mortality (M&M) rounds. Unlike a jury trial in Canada, in which the defendant is presumed innocent, the Burden of Proof falls to the Most Responsible Physician (MRP), and frankly, the trial is fixed: you feel more like you are a spectator at a public caning. Most likely, you are feeling sorry for the hapless MRP, as you sink lower and lower in your seat. You feel a sneaking sense of relief as your inner voice murmurs “thank goodness, it didn’t happen to me and it wasn’t my case.” And, at the same time, you cannot help but think “that could have happened to me – that could have been my case,” and then you whisper a little prayer and hope that “it won’t be my case next time.”

It could be worse: you could, in fact, be the hapless MRP, in which case, you are most likely feeling like a victim of a public stoning by your colleagues and peers.

During these times, have you ever wondered what our trainees are thinking, sitting there in the audience and taking this all in? What are we teaching our learners? What are our learners learning from this spectacle, this live “demonstration of medicine’s old shame and blame culture,” whose underlying dynamic is finger pointing and blame?

The National Patient Safety Foundation (NPSF) published “Unmet Needs: Teaching Physicians to Provide Safe Care. Report of the Lucian Leape Institute Roundtable on Reforming Medical Education” in 2010, proposes a very different vision of M&M. The document calls for a profound change in the culture and structure of both the health care system and medical education, to place the “highest priority on creating learning cultures that emphasize patient safety, model professionalism, enhance collaborative behavior, encourage transparency, and value the individual learner.” In addition to highlighting the importance of interpersonal skills, leadership, teamwork, and collaboration among faculty and staff, the need to explicitly teach and articulate these skills is stressed. And in the spirit of systems thinking, the document challenges medical schools, teaching hospitals, leadership, teaching faculty and other stakeholders, to support faculty to teach safety to students.

Our White Paper working group was inspired by this document, as we considered the creation and implementation of patient safety curricula into all levels of medical education, including MOC. We challenged ourselves to dream about how the teaching of safety would look like and how the Royal College could be an agent to promote this profound change. In the “Just Culture of Patient Safety” FMEC white paper, we have proposed that teaching and assessing the Patient Safety Competencies must become a mandatory and explicit part of PGME program curricula. And for faculty to effectively teach these competencies, which include teamwork, interprofessional collaboration, and communication skills, there needs to be faculty development and continued professional development for teachers and practicing physicians. We recommend that systematic strategies to measure and change the working and learning environments to support a patient safety culture be implemented.

One can dream about what M&M rounds could look like, would feel like, in a safe, supportive environment, which embodies a just and learning culture, and one that is, moreover, mindful of Quality of care or Quality improvement legislation to ensure a protected environment for discussion. So, what commitment would it take on our part as clinicians, and as teachers, to make this type of environment a reality?

Dr. Amy K. Nakajima, MD, FRCSC

Posted in Original Posts, Patient Safety, Posts by Topic, Uncategorized | Leave a Comment »

Dual Role: A Resident’s View

November 22, 2011 by rcpsc

To a novice commencing a surgical residency,  procedures such as chest tube insertions, inguinal hernia repairs and abscess drainages constitute the greatest educational opportunities out there with no competition from chief resident who may not derive so much education from doing such cases. What is and where is the dividing line between service and education? What is service?

Perhaps it’s the routine tasks that are performed in an automatic fashion following repeated performance, or the surgical procedures that you will not be performing after a subspecialized fellowship. Consider a surgical resident who is planning to sub specialize in thoracic surgery, he will not find scrubbing in a Delorme procedure as educational as someone who is going to subspecialize in colorectal surgery.

More commonly, service encompasses taking history and physical, checking labs, doing EKGs and writing notes. But who can for certainty deprive service from it’s educational value? It is argued that all work related to patients care has an educational value one way or another. If service does not contribute to the scientific knowledge then it certainly teaches management skills, prioritization and leadership skills. Research into this area is certainly lacking.

The Royal College recognizes in its white paper on resident dual role the challenges to residency education due to work hour reduction. The need is not simply to look at service to education ratio but to utilize every single moment efficiently during residency in order to produce a competent physician.  Since we can’t have a global definition of service then we should trust the adult learners i.e. the residents. We should give them the freedom to define what is service and what is education in a controlled fashion. This would fit perfectly with competency based residency training which gives more control to residents in sculpting their training.

Whenever I think of service to education I recall my time at the Glasgow Royal Infirmary in Scotland where I was an intern. I used to walk the notorious long Link Corridor sometimes 4 times a day to deliver x-ray requests. One trip used to take me at least 20 minutes. It was beneficial in terms of time management skills but did not contribute much to my scientific knowledge.

Time in the era of reduced work hours is of an essence. It should be dissected thoroughly and used properly towards producing high quality residents. The issue of service to education may best be left to individual residents to define. After all residency education is an adult learning process.

Mohammad H. Jamal MBChB(Hons) MEd FRCS(C)
Hepatobiliary and Transplant Surgery Fellow
McGill University

Posted in Posts by Topic, Response Posts, The Resident's Dual Role, Uncategorized | Leave a Comment »

Generalism: Teaching the Importance of Relationship Building

October 18, 2011 by rcpsc

Dr Wilson in his blog introduces the concept of “motherhood and apple pie” as akin to generalism; we know what it is when we see it – but have a hard time defining it. What is missing from this is the fundamental underpinning of both motherhood and generalism: relationships. Much of what is discussed around the theme of generalism is how we must value, respect, promote and train for it – but what has been lost in the debate is the critical importance of personal interactions.

 As the more generalist disciplines including family medicine, pediatrics, psychiatry and to some extent general internal medicine, have moved to more outpatient focussed practice, the loss of the networking effect of seeing colleagues in the hospital hallways, interacting at lunch, in the ER and at rounds has been profound. This is seen more in larger urban centres where the focus has shifted to highly specialized tertiary care versus smaller, regional and rural areas where physicians of all spots see and know each other – and talk! Considering that the vast proportion of the patient population is seen and cared for outside tertiary environments, the move to distributed medical education is very positive on many fronts. Physicians trained in a particular environment are far more likely to practice there  – and to know the other health care professionals they work with.

 In losing these professional interactions, the value of the services we all provide can become blurred and misunderstood. Enter the hidden curriculum – very insidious and operational on many different levels. Uncertainty of competence takes the place of collegiality and acceptance; generalists frequently operate in a world of “grey” with undifferentiated problems; confidence and competence in dealing with these are key generalist attributes along with the patience to wait and see! But this translates to a sense of doubt when, as the clinical situation unfolds and a diagnosis presents itself, earlier patient interactions are discounted by a consultant colleague. The reverse also holds true when a referred patient returns with unmanageable recommendations in the face of personal circumstances.

 Well established relationships go a long way to mitigate this: personal interactions, a network of “who you gonna call” when challenging situations present themselves; a knowledge that we are in this together to provide service to our patients as part of the health care team. Consider further how relationships influence where we work – retention of physicians in smaller centres is largely influenced by the relationships they develop there – with the community, with colleagues, with patients. Nothing is more rewarding than a long-term relationship with a patient and their family – and the feeling that you really have made a difference in their lives. Capture and bottle this – there you have generalism at its best.

 Maureen Topps MB ChB CCFP FCFP

Posted in Generalism, Posts by Topic, Posts by Type, Response Posts | Leave a Comment »

On “Generalism”

October 11, 2011 by rcpsc

Like motherhood and apple pie, the concept of “generalism” is one that is accepted as an important value in medical practice and as a consequence an important value to instill in our students and residents. This would be easy to accomplish if we all agreed on exactly what “generalism” means, that we had some strategy to evaluate “generalism” and we valued the current generation of practicing generalists. There seem to be as many opinions on the meaning of “generalism” as there are practicing physicians.  

We hold in high regard the dedication of the old-time general physician working with highly developed clinical diagnostic skills but limited therapeutic options who delivered babies, sutured lacerations and set broken bones, made house calls to the ailing and comforted the dying. In our era of technology dependent, interprofessional care delivery systems, the solitary physician working alone is no longer a viable model.

We do need and still value the increasingly rare modern rural general specialist who is able to care for a wide range of patient problems in challenging settings. A significant number of these physicians have trained in non-Canadian jurisdictions and seem better equipped for practice in rural settings than our own Canadian graduates. We clearly need these physicians inCanada, with its huge geography and widely dispersed population. Our education system needs to respond more effectively to this challenge. 

However, in the more common urban/suburban setting where the majority of Canadians live, what value to we place on a generalist practicing in the midst of wide range of available specialists and sub-specialists?  Some patients and many sub-specialists tend to undervalue and look with unjustified biases, on the care provided by these physicians, fearing that this care is not to the same standard as that provided by the hyper sub-specialist. In an age of increasing disease chronicity and complexity, increasingly complex and difficult contexts for care provision where the root causes of ill-health and disease are difficult to alter, we need to prepare learners to undertake comprehensive broad based clinical practice on completion of training. We need to encourage them to maintain an open mind and continue to accept challenging patients with undifferentiated problems. As Canadians we need to value generalists and encourage them to continue to provide broad based, coordinated care.

 The white paper on generalism attempts to address the definition of what generalism means in 21st centuryCanada and to begin the discussion as to how to design and value the concepts of generalism in postgraduate medical education and in continuing clinical practice.  

James W.L. Wilson MD FRCSC

Posted in Generalism, Original Posts, Posts by Topic, Uncategorized | 1 Comment »

Residency Training in the 21st Century: Planning Learning for the Needs of Tomorrow’s Doctors

October 4, 2011 by rcpsc

Canada’s diverse population will need health promotion, prevention and patient care that is provided appropriately for those who live in the most challenging inner city environs, and in rural and remote communities, for Canada’s First Nations, Inuit and Metis, and the newest Canadians who come as refugees, and for every one in between.  For the health care system to provide care needed for such a diverse and distributed population it will surely require physicians who have developed an experiential understanding of Canada’s peoples and their community and health care contexts. It is difficult to impossible to get that if one’s postgraduate residency training occurred only in one major site as the healthcare system challenges faced by both patients and their healthcare providers including doctors differs dramatically with these diverse contexts.

 This does not mean that every postgraduate residency should have the same mix of geographic and other contextual learning.  For example, there still exists a significant need to educate more doctors with the specific knowledge, skills, and interest to practice in rural and remote settings.  We know now that this best occurs when a significant portion of training is undertaken in small and midsized communities.  Similarly, the training of general internal medicine, general surgery, psychiatry and other specialists for small and mid-sized regional cities can be improved when a significant portion of their learning experience takes place in such settings where there are both appropriate role modelling and opportunities to identify their further learning needs based on the knowledge and skill sets they see are required. 

 On the other hand, it would be unrealistic and inefficient to expect physicians who are training to become very highly technical focused subspecialists to spend a lot of their time training outside major tertiary care referral centers.  I would posit however, that even the most highly sub-specialized physicians can benefit from a short learning experience in smaller regional centres where they can develop a better grasp of the healthcare system challenges faced by patients and the physicians and others who look after them, far away from the highly technical equipment and specialized teams that surround them for most of their training and future practice. Bi-directional understanding and communication can be enhanced when tertiary care sub-specialists come out to regional centres to provide outreach clinics and CME.

Dean James Rourke

Faculty of Medicine
Memorial University of Newfoundland
FMEC-PG Management Committee Member

Posted in Diversified Learning, Posts by Topic, Posts by Type, Response Posts | Leave a Comment »

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