Dr. Brian's Advice to Budding MDs

Think your doctor lacks empathy?  Makes you wait too long in the reception area?  If you only could give your GP a piece of your mind. Lucky me!  I had the singular honor of being the keynote speaker at the Oath Ceremony for medical students graduating from McMaster University last May.  Here's what I think the next generation of MDs should strive for.

Dean Kelton, members of the faculty, distinguished guests, Graduating Committee, proud parents and other family members and friends, ladies and gentlemen. It is a great honor and a privilege for me to deliver the keynote address here at the Oath Ceremony of the 2012 Graduating Class of the Michael G.DeGroote School of Medicine.

That's a pretty flowery start for an informal guy like me.  And if you don't mind, I'm going to dispense with the formalities from here on in.  I was given but fifteen minute to fill your heads with a short course on how to practice and how to live. My TED talk was three minutes longer!

Let me begin by asking each one of you amazing graduates today a question:  How are you? How are you doing?  In fact, I want each of you to turn to a fellow graduate on either side and ask them "how ya doing?"

If you're being honest with yourself, my question may be making you feel a bit uncomfortable.  It should.  I'm not saying that graduating from medical school isn't supposed to be an auspicious and wondrous occasion for you and for your family.  And for all I know, what pops into your head at this moment are words like proud...excited...happy.  

If someone had asked me how I felt on a similar day in May more than thirty years ago, I might have used words like anxious...uncertain...and scared. And if you feel like that today, frankly, I don't blame you.  

A few weeks ago, when I started thinking about what I was going to say to you today, I approached the Graduating Committee with an offer to talk about what it feels like to make a medical mistake that harms a patient. Not surprisingly, they said yes. But then, one of them mentioned something in passing that stuck inside my head and changed completely what I was going to talk about. He informed me that ten percent of the graduating class of 2012 didn't get placed into a residency position in the first round of the recent CaRMS match.

For the uninitiated, CaRMS is short for the Canadian Resident Matching Service, a not-for-profit organization that provides a computerized system that matches graduating students with postgraduate residency programs throughout Canada.  The students first have to figure out what kind of residency they want to do - in effect, what they want to do for the rest of their lives. Then they interview and check out residency programs across Canada and rank them according to their preferences.  That's an arduous and often nerve-wracking task. Meanwhile, residency programs rank graduating students in much the same way.

Imagine for a moment what it might feel like to go through that process while trying to finish your rotations and graduate - only to find yourself unmatched - and at least for the moment - with no residency program to go to. My Graduating Committee informant tells me that ten percent of the graduating class failing to get matched on the first round is  "quite different from the norm."

Before I go on, let me stress that this situation is no reflection on the lofty calibre of medical students who graduate from the Michael G. DeGroote School of Medicine and McMaster University.  The school has an enviable track record of producing many of Canada's finest and most well-rounded physicians. It, and you have every reason to be proud of your achievement.

Nevertheless, in my view, what has happened to these students symbolizes something important.  For the ten percent who didn't get matched, this is one heck of a reality check for a group of worthy students who have worked extremely hard to be successful.  

More than that, I reminds me that even bigger changes are likely in the air.  Times are going to be tougher for you - the MDs of tomorrow - than they were for people in my class.

I believe that yours will be the first generation of physicians in a long time that may feel the need to justify to Canadian society the value of the work we do in an almost existential way. The signs are everywhere.

"Are We Facing a Doctor Glut?" went the headline on the cover of The Medical Post on January 31st of this year.  Dr. Dawn Ng - whose photo graced the cover of the magazine - told a story that is becoming increasingly commonplace these days.  Next month, she completes her residency in medical oncology with no job in sight.

"I'm looking for jobs.  But there just aren't any out there," she told The Medical Post. "If you hear of anything, let me know."

Ng told the Post she isn't alone; most of her classmates have nothing lined up.  A report by the Royal College of Physicians and Surgeons of Canada found that as of two years ago, new specialists in cardiac surgery, nephrology, neurosurgery, plastic surgery, ENT and radiation oncology were having difficulty finding work.

Cardiac surgery is in a class by itself.  In a survey of 50 graduates of Canadian cardiac surgery training programs between 2002 and 2008, which was published in the Annals of Thoracic Surgery, most got the jobs they wanted - eventually.  But one in three of them considered themselves underemployed, and more than one in four said they had to extend their training - to an average of nearly ten years after medical school.   All but one of those surveyed said finding a job was difficult or extremely difficult.  Study author Maral Ouzounian, herself a newly-minted cardiac surgeon, told The Medical Post that many of her peers have ended up working as surgical assistants, while others have gone off to Europe and the US in search of work.

Some of the reasons for this are well known.  Medical school enrollment, which was down around 1,500 in the mid 1990s, has nearly doubled.  At the other end of their careers, older physicians - whose retirement savings took a hit during the global financial crisis that is four years and counting - have postponed retirement.  The result - say many observers - is a glut of MDs.
In my opinion, much of the problem is lack of planning and coordination of health human resources - and an almost complete lack of basic figures regarding who does what and for how long.

Depending on the specialty, there may be factors at work - things like changes in the practice of medicine.  Once, when the coronary artery bypass was the only game in town, cardiac surgeons cornered the market. Then, angioplasty emerged as a viable and much quicker and less elaborate alternative to surgery.  Cardiac surgeons made what I think was a huge strategic blunder:  they failed to embrace angioplasties. In so doing, they left the procedure wide open to cardiologists - who reinvented themselves as 'interventional cardiologists' and cornered the emerging market.  Today, they flourish...and cardiac surgeons go unemployed.

Even family medicine may soon face a surplus and the potential for unemployment. Frankly, family medicine has something even bigger on its plate these days - something else that adds to your uncertainty and theirs. From my vantage point, I see family medicine undergoing an existential crisis with implications on both sides of the gurney, as I like to say on White Coat Black Art.  Will the 'real' family doc please stand up?  Is it the well-trained all purpose Jack and Jacqueline of all trades?  Or is it the budding emergentologist, palliative care physician, GP anesthetist, primary care obstetrician, hospitalist - specialists in every way but how they call themselves.

Adding to the changes in the wind:  let's not forget the rapid emergence of other health professionals - some of them trained right here at McMaster.

In 2007 Ontario's Ministry of Health and Long-Term Care announced the creation of 25 Nurse Practitioner-Led Clinics.  Three years ago, I visited the Sudbury District Nurse Practitioner Clinic, the first of its kind in anywhere in North America.  At clinics like the one in Sudbury, it's the nurse practitioner or N,  and not the physician who is lead provider of primary care - the gatekeeper if you will.  They're helping to reduce the orphan patient population in northern Ontario and elsewhere.

Physician assistants or PA's are yet another new player on the health care scene.  Actually, PA's have been around in the US since the mid-1960s when severe shortages of family physicians led the system there to go looking for a new type of professional to fill the gap.  The initial ranks of PAs in the US were drawn from battlefield medics who acquired considerable field experience treating sick and wounded soldiers during the Vietnam War.  Nowadays, there are numerous accredited PA programs in the US, and a small but growing number in Canada as well - including the cutting edge program right here at McMaster.  

Last year, one of your earliest and most illustrious PA graduates - my friend and former CBC colleague Maureen Taylor - helped look after my dad when he was admitted to Sunnybrook Health Sciences Centre in Toronto last summer.

At Mount Sinai Hospital's Emergency Department, I've worked with both PAs and NPs and have thoroughly enjoyed collaborating with them. They have played a fundamental role in helping us meet our provincial targets to see patients in a timely fashion.

In Nova Scotia, they're training a new breed of paramedic. There, instead of always scooping up patients and transporting them to hospital, specially-trained medics like Darrel Bardua attend to ill seniors at nursing homes in the Halifax area - sewing up cuts ordering tests and administering intravenous fluids. In so doing, they save more than two-thirds of the patients they see an unnecessary trip to hospital.

I predict that once more Canadians gets a taste of what these new professionals have to offer, there' will be no turning back.

Could I find myself unemployed one day soon?  I wouldn't be so arrogant as to bet my life savings against it!  Is that the way it goes?  Will public finance issues lead the provinces to seek cheaper alternatives to physicians?  Will our society end up with fewer of us - perhaps none of us?  Imagine that for a moment.  MDs making like dinosaurs, bell-bottoms, eight track tapes (now I'm really dating myself) and Madonna!

You know what?  I don't see that happening at all for a number of reasons.

First, there are numerous obvious examples in which physicians are for now and likely for many years to come - irreplaceable.

Let's start with surgery, for example.  You could probably train a nurse practitioner or a physician assistant to take out an inflamed appendix.  I'm not certain you can say the same for an NP or PA doing a Whipple procedure or a double lung and heart transplant.

How about a robot like NeuroArm, a surgical robotic system that in 2008 helped remove a tumor from the brain of  21-year old Paige Nickason.  But replace the neurosurgeon at the controls of the robot?  Not any time soon, says neurosurgeon and NeuroArm co-inventor Dr. Garnette Sutherland of Foothills Hospital in Calgary.

That spark of creativity is yet another attribute that makes physicians irreplaceable.  It's found in the ability to turn a telescope and a TV set into minimally invasive surgery.  It's also found in the ability to turn an iPhone into a motion sensor that can tell the difference between the intention tremor of Parkinson's disease and the shakiness of alcohol withdrawal.

Next, consider what we might call the 'medical mind' and a wonderful bit of alchemy called the diagnosis.  Being a decent diagnostician involves little bit of technical skill, some well developed powers of observation, and of course, experience.

Most of the process of arriving at a diagnosis goes on between our ears. Thankfully, it can't yet be replicated by guidelines and heuristic algorithms.  I'm talking about the ability to observe things in a patient that tell us something bad is about to happen. It's a flash of diagnostic insight that informs me (correctly) that my patient has cancer. It's the spark of intuition that urges me to move a patient with abdominal pain into the resuscitation room because she's about to have a cardiac arrest. It's what author Malcolm Gladwell likes to call the 'blink' moment.

Blink is all about rapid cognition, about the kind of thinking that happens in a blink of an eye.  One of my favorite stories in "Blink" is about the Emergency Room doctors at Cook County Hospital in Chicago. They changed the way they diagnose heart attacks by gathering less information and just focusing on simple things like blood pressure and the patient's electrocardiogram or ECG.  In other words, they encouraged the 'blink' moment, and in so doing turned Cook County to one of best places in the US to go to if you happen to have chest pain because they get it right.

Still, I began by saying you may well have to justify your existence in ways my generation didn't have to.You must not take it for granted. You will have to sell yourself as never before.  To do that, you need to reflect on what it is we do in health care that is both unique and laudable.

Here are just a few of the examples I've come up with:

First, like most other health professionals, physicians are among the most ethically grounded people on the planet. This is terrain you should claim and own. Aspire to create an ethical framework for everything we do - and then do it.  

Closely related to ethics are personal and professional integrity. Many of you know that in the past, I gave talks on pain management that were paid for by Purdue Pharma, the makers of OxyContin, which the company recently stopped selling - in large part because of an epidemic of OxyContin abuse. As a result of my experience, I no longer believe physicians should participate in industry-sponsored continuing education.  And yet, at the same time, I believe we must find a modus vivendi for pharma and the medical profession.  

Pharmaceutical companies aren't going away. Neither are you. I think it's hypocritical for critics to thumb their noses at drug companies while prescribing their wares avidly. I challenge you to find a new way and a new set of rules for a system in which physicians and pharmaceutical companies coexist.

As you know from my TEDtalk earlier this year, I said we must create a culture of safety in medicine - not by berating or shunning colleagues who make mistakes - but by embracing them and encouraging them to talk about their mistakes so that all of us can learn from them.

A wise friend and colleague who once worked as a urologist in this very city once told me good judgment comes from experience. And experience comes from bad judgment. In other words, to become a great diagnostician, you have to be willing to risk failure and to learn from your mistakes.

Last but not least, rediscover the power of empathy in your patients'  well-being and yours.  Many people in medicine fail to put empathy in their toolkit.  Maybe they see it as a soft skill - something you offer up when you've run out of potions and cures.  My late friend and colleague Dr. Robert Buckman was an expert without peer at communicating with patients.  Rob said that many physicians made the mistake of assuming that empathy could not be taught - that you are either an empathic person or you aren't. He said you can teach physicians how to be empathic to patients about as easily as you can teach them to set a broken arm. Rob once taught me how to use the empathic response when breaking bad news in the emergency department. He was right. You can learn it.

Let me close by congratulating you on your wonderful achievement. And, by welcoming you a wonderful calling.

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