Friday, January 11, 2008

'The Envy of the World'™

For decades, Canadians have believed that the rest of the world is wildly envious of our socialized medical system. If this is true, it's just a reflection on how long it takes for the truth to percolate through delusion. To people who know anything about our dirty hospitals, our half-day waits in Emergency rooms, our lack of doctors, our sclerotic bureaucracy, Canada's system is an example of what to stay away from. Now the CMJ is advocating reducing the number of years we train our doctors, to combat the doctor shortage that comes of underpaying them and trapping them in a control economy.
Canada's top medical journal is raising the prospect that the country's medical students could spend less time in school to save time and money and help reduce a shortage of doctors.
My immediate feeling was "Uh-oh". It's not like we've got a pristine system running at 110% efficiency, and can afford to relax. Stories like this, as well as the SARS outbreak in Toronto's hospitals give all the signs of a frayed and overstretched system. So now we're going to push into the community doctors with LESS training?

I asked a friend in the US her opinion, since she's now interning and has almost completed the whole, lengthy process of becoming an MD. Naturally, she was much more eloquent and incisive than I could be, so I'm just going to post her email here:
The problem with trimming down medical school is that you'll basically end up with doctors who function at the physician-assistant level, and then there's no point to calling them "doctors." The major difference between physicians and mid-levels (PAs, nurse practictioners) is the amount of education devoted to understanding details of physiology and pathology. Mid-levels are taught to provide care in an algorithmic manner that doesn't necessarily require understanding of the disease process. This is very effective for common and minor complaints, and these people can be very helpful in seeing large numbers of patients. The problem comes when you have more complicated issues. I feel pretty strongly that even the 4-year medical education provides the minimum framework for understanding medicine. Considering that most specialists have 4 years of medical school, 3-4 years of residency, and 3-4 years of fellowship before they start to master one organ system, I think it would do the public a disservice to deploy groups of minimally-trained physicians. It's also important to remember that medicine is getting more and more complicated as our scientific knowledge expands. Most older physicians will say that when they went to med school, many of their courses had half (or less) the amount of material that they do today (the most dramatic examples would be pharmacology, immunology, and genetics). People grumble about there being too many specialists, but I think we are headed in a direction of needing those specialists as people live longer with more difficult medical issues.

It's also important to remember that part of medical-school training involves research--how to go about designing studies, analyzing data, and publishing findings. I'm sure a lot of people feel this could be cut, but even doctors who don't intend to do research need to know how to understand medical journals and publish their interesting clinical cases. As far as I know, PA/ARNP schools include very little of this training, and I don't see a good way to squeeze it into a condensed medical school curriculum.

This idea of shortened medical education has been proposed in the US too, and it has been shot down for the reasons I mentioned above. I think it would be more reasonable to try to train additional mid-levels to relieve some of the burden on the system. They are perfectly well qualified to deal with general medical issues with a supervising physician as a back-up. Trying to fast-track medical school would create more problems in the long-run as the competence level of doctors declined.

One thing I noticed about this story is that neither article - from the CMJ or from the Ottawa Citizen - included a single quote from a doctor opposed to reducing doctor's training. They feel it is enough to say that "nobody's complained", but I doubt that the average person even knows how many years of training his or her doctor has had, or how much is normal.


Blogger Dr. Alice said...

Hurrah for your friend, with whom I completely agree. She expressed what I would have said much more eloquently than I would have. With your permission, I'd like to link to your post.

Incidentally, if you do find any negative responses to this proposal from Canadian physicians, I'd certainly like to hear about it.

3:06 pm  
Blogger Dr. Mabuse said...

Please feel free to link away, Doc! I think it's rather alarming that something like this is being promoted with very little in the way of balanced argument, at least among the lay public.

3:36 pm  
Anonymous Mrs. Falstaff said...

I don't advocate reducing training time for doctors, but I think you are too hard on our medical system. I'd much rather have the system we have, than have to deal with a system in which people put off going to the doctor for too long because they are afraid of the costs involved.

2:07 pm  

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