Unanswered Questions

Two weeks ago, a twitter town hall was held to canvass issues of importance to Ontario doctors in the elections for an Ontario candidate for CMA President. This is my response to five questions left unanswered at the end of the town hall.

The leftover questions included some questions on global health, mental health and relativity in doctors’ fees and my goal is to address all of these issues in this article.

In two tweets, Dr. Naheed Dosani noted that at CMA General Council in 2011, a motion to support education in global health in medical school curricula was defeated. He asks what my position is on global health training for future physicians. I recall that the concerns raised during the debate at General Council included the view that medical education was already intense and that each General Council brings at least one or two new areas of study that must be included in the education of a physician as our knowledge of health and health care progresses over the years.

Some of these new areas of study that have recently been introduced into medical school curricula include the use of electronic/hand held devices and, in some parts of Canada, basic details about clinical practice guidelines.  In this age of ever increasing amounts of information, it is not difficult to understand how General Council delegates might have decided that there had to be a limit and refuse to recommend the addition of global health to the standard curriculum.

Leaving aside the entire issue of who should decide what does comprise the Standard Curriculum to the work of The Future of Medical Education in Canada project, let me say that, as a delegate to the World Medical Assembly on behalf of Medical Women’s International Association, I believe that there are some basic elements of global health that must form part of what students in medicine learn. SARS and the H1N1 pandemic have demonstrated in no uncertain terms that something of global health must be taught to all medical students with the determination of how much being delegated to those with a particular interest in medical school curriculum.

In the same way, however, that students and residents are going to develop particular interests in specialized areas of health care, some are going to develop an interest in global health and electives in global health need to be developed so that Canada continues to play a vital role in this increasingly important area of health care. As the world shrinks, what is a concern half way around it can quickly become a concern in Canada. Also, in some areas such as mental health, more recently a concern in developing countries, Canada can provide much needed expertise in the diagnosis and treatment of mental illness. For all of these reasons, I support the view that Canada’s medical schools ought to be able to teach the basics of global health and support an interest in global health as a career. With a Canadian at the helm of the World Health Organization, we have a constant reminder that Canada has fostered expertise in global health in the medical profession.

The Ontario Psychiatric Association and its members raised three questions during the town hall. One question asked how I, as CMA President, would support a National Mental Health Strategy as well as for my thoughts on the underfunding of mental health issues in Canada.

I will first consider the underfunding of mental health care in Canada by describing how it has recently affected my own patients in my own practice. In November 2010, a young woman in my community took her own life, a tragedy that occurs too often all over Canada. The difference this time was that this girl had a famous father and her parents used their influence to engage youth in a campaign of public awareness of youth mental health. The success of that program has seen a 30 % increase in referrals to my program without an increase in funding, with the result that the Youth Outpatient Psychiatry Program struggles to meet the need of the community we serve. Investments made by the provincial government for the mental health care of the population my program serves have all gone to community agencies instead of psychiatric and hospital services. While Canada now finally has a National Mental Health Strategy, the means to fund that strategy are still emerging and it is clear that we still have to convince provincial governments of the need to fund medical mental health services.

Advocacy for increased funding for mental health means that our communities must develop concrete plans for the resources we will need in years to come.  The CMA’s contribution to this has been to support the efforts to understand the physician human resource needs in psychiatry, which suggest that we are facing a shortage of psychiatrists, especially in child and geriatric psychiatry. Even considering that psychiatrists have long experience with interdisciplinary care, a focus on mental health and how we address mental health concerns must begin to be addressed on a national level.

I f we move on to consider how CMA can support Canada’s Mental Health Strategy, as released by the Mental Health Commission of Canada, promoting the dissemination of this among physicians would be a start as the CMA has been supportive in the Canadian Psychiatric Association’s advocacy efforts and is already on record as supportive of the direction the strategy is taking. Nonetheless, Canadian doctors are, in general, unfamiliar with the strategy and CMA could assist in its promotion.

Another issue raised by the Ontario Psychiatric Association was that of the Ontario government’s plan to increase the number of casinos in large towns in Ontario. I have already included a link from my webpage to a letter I wrote to the Ottawa Citizen which did address some of these concerns. The letter was written in response to an investigative series of articles by reporter Louisa Taylor. The link to the series is http://www.ottawacitizen.com/health/Part+Weighing+risks/7775520/story.html and the link to my letter is http://www.ottawacitizen.com/health/Glamour+gambling+seduces+young+people/7810297/story.html

A question raised by another tweeter, Dr. Scott Wooder, asked for a consideration of relativity. The issue of income relativity is an important one for physicians and medical associations across Canada have found ways to address the disparity in incomes between different physicians, particularly because lower rates of payment can seriously affect recruitment into various specialties. In fact, there had been a serious problem in many parts of Canada several years ago that few medical school graduates were selecting family practice as an area of specialization because of the poor remuneration. Improved payment, particularly because of the implementation of relativity formulae, has seen a reversal of this trend.

When I spoke about the concerns about the recruitment of psychiatrists earlier, it is also the view that the fact that psychiatrists (along with pediatricians and other consulting medical specialists) are among the lowest paid physicians has hindered recruiment. With people finishing their residencies with ever increasing debts, there is a concern that the final income of a specialty might sometimes be a consideration in the choice of a career. For this reason alone, relativity must always be a factor when physician incomes are being considered. It is my view that this is one area in which the CMA can act as a clearinghouse for best practices with respect to relativity research around the world. I have a personal bias, having chaired the OMA’s CANDI Relativity Implementation Committee, but I believe that OMA economists, Dr. Boris Kralj and Dr. Jasmin Kantarevic, are some of the best resources in Canada with respect to this issue.

While this article does bounce around between various topics in an effort to address the questions unanswered because of short timelines in the twitter town hall, what it does demonstrate is the capacity of social media to raise a number of issues that are of importance at present. As always, I am fully prepared to hear what you think about these various issues and to address your concerns. Since relativity was one of the issues raised, anyone who has been at OMA Council for the past three years will know that I addressed numerous concerns around the issue of relativity, often spending an hour or two reviewing the findings of the committee I chaired. Good discussion produces better policy.

 

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s