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AFMC 2018 presidential address: Our past, present and future

The following speech was given at the AFMC Presidential Address and Awards Ceremony on April 29, 2018 during the 2018 Canadian Conference on Medical Edition at the Halifax Convention Center.

We Have Come a Long Way

As you may have heard the AFMC is celebrating its 75th Anniversary this year. In fact, 75 years ago, Dr. Alvin Mathers, Dean of Medicine at the University of Manitoba invited his colleagues, then from a handful of faculties of medicine from across Canada to meet with him in Ottawa in 1943. His invitation suggested a meeting of the minds for the purposes of discussion on matters related to medical education. In fact they were really meeting to discuss the Canadian government’s requests to the country's medical schools to double the number of medical graduates to meet wartime needs.

Postwar demands on the schools focused attention on the need for nationwide planning and action. A process for information exchange among the schools was inaugurated, and the Association of Canadian Medical Colleges, the precursor to the AFMC was born, becoming the repository for data on students, residents, faculty, and the health workforce. At our Board meeting yesterday we confirmed the AFMC data vision moving forward to enable us to better support, inform, and advocate for our faculties and our academic medicine community as we work to have a greater influence on policy makers and funders.

It’s hard for me to believe that this the 5th time I have had the privilege of addressing you as President and CEO. In this fifth year, I have taken the opportunity to do a cross country tour and visit our faculties of medicine. I met with our Deans, their leadership team, those who are working with AFMC data, the AFMC Student Portal and most importantly learners including medical students, residents and graduate students.  

I was reminded of the extent to which our academic health science networks are extraordinarily vibrant and evermore complex. Our clinicians and scientists are asked to function in an environment where they are being more closely monitored, where financial reporting has become almost absurd, where everyone has to be more accountable. And for our clinicians where electronic medical records are being implemented (yes, even I got EPIC’ed this year in my clinical realm in Pediatric Emergency Medicine at the Children’s Hospital of Eastern Ontario in Ottawa), and where having hospital privileges requires jumping through more and more hoops than ever before. 

Despite all this, our researchers continue to make the most of incredible discoveries and identify innovative ways to translate that knowledge into improved care for patients, and our educators continue to transform curricula and learning experiences to respond to the social accountability mandate of our faculties.  I am always blown away by the dedicated people who make all this happen day after day.

Yet, We Have Much to Do

The problem is that these people; these brilliant dedicated people, (and in that I am including not only our clinicians, our scientists, our administrative staff, but also our learners) are exhausted, they are stressed and they are burning out. At this conference we have heard and will hear more about the devastating effects of these challenging work environments on all of us, leading us to, at times, not be on our best behavior, sometimes resulting in “bad behavior”, occasionally really “bad behavior”. The worst of it is that we know that all of this has a direct negative impact on patient care and patient safety.

As leaders in our academic health science networks it our role and it is our responsibility to fix this. But how? Well, as we are instructed to do when there is trouble in mid-flight, first we need to put on our own oxygen mask, and then we need to help everyone around us to do the same. We need to start with our faculty.  When our scientists and clinicians are faced with challenges we need to find ways to help them. When they have exhibited behaviors that are not acceptable we need to find out why and support them through any related issues, including addiction and mental illness.  

We need to create a culture where it is OK for anyone to come forth with these issues and on the road to wellness. And we need to create, as coined by Sidney Dekker, a Just Culture based on trust, learning and accountability looking forward to what must be done to repair, to heal and to prevent in a way that is respectful to all parties.

We must respect and expect respect. We must respect and expect respect. On rare occasions some individuals are unable to abide by this simple principle and, in cases where their behavior is not related to health issues these individuals need to be removed from our environment. This takes courage but it must be done. To quote Maya Angelou “I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel”.

During a recent episode of White Coat Black Art on the #metooinmedicineCanada movement, Brian Goldman interviewed a female medical student who spoke of a devastating sexual assault by a male clinical preceptor. It was reassuring to hear her state that she considered that the medical school had acted swiftly and decisively regarding any further contact with students. However, when dealing with the authorities and the legal system, she felt completely overwhelmed and did not consider that she was well informed or supported. We need to do better in that realm.

It is also our responsibility to create positive work and learning environments where all voices are heard. We need to enable, facilitate and reward mentorship recognizing that people’s needs may differ. We need to cultivate a renewed focus on compassion and caring not only for our patients, but also for our staff and our learners.  If our clinical settings are focused on what is best for the patient, then that sends a clear message to any learner that this is what health care is all about. I know that all of our faculties have pockets of excellence where this is the case. How do we ensure that this becomes the norm? In such an environment we will be encouraged to treat each other as care providers, as teachers, as researchers with the respect that we all deserve. Each and every one of you can be part of the solution.  As the Dalai Lama has taught us “if you think you are too small to make a difference, try sleeping with a mosquito”.

Support for our learners needs to extend not only to the provision of excellent curriculum, clinical experiences and learning environment but also to the support we provide them in their career decision making. As we know, our medical students spend more time worrying about how they will be matched to residency than just about anything else during medical school. It didn’t used to be that way nor should it be. But with 169 unmatched graduates of Canadian medical schools which includes 115 current year and 54 prior year graduates, who can blame them. I commend the work of our undergraduate and student affairs offices that have done a tremendous amount of work in providing career counseling and support for these students and graduates.

What we need to do is to re-think the structure of the final year and the way we frame opportunities to experience various entry disciplines. It is not reasonable to expect that a student spend months in one entry discipline to appear competitive to match in that discipline. That was never the purpose of the final year. On the flip side, we need to think about those entry disciplines. Does it really make sense for a first year medical student to have to consider a list of 30 different entry routes into residency? We have to consider this question from a social accountability perspective. This is why we need to work with all stakeholders, including government, to ensure that our students are entering into a postgraduate medical education system that will allow them to respond to the needs of the population and successfully enter the workforce. 

We were certainly very pleased with the announcement earlier this month by the province of Ontario to fund up to 53 positions in certain generalist specialties based on societal needs and the Canadian Armed Forces who are looking to enlist and train graduates in family medicine. We look forward to hearing about solutions in other jurisdictions across the country. Now is the time to work with all stakeholders to deal with the ongoing uCMG crisis in order to make a significant impact for match 2019. 

Shaping the Future

In celebration of our 75th anniversary, the AFMC commissioned a Commemorative Booklet which is a collection of reflections of the past and thoughts about the future from our greatest leaders in Canadian Academic Medicine. The e-booklet will have been posted on our website and sent to our mail-out list as I speak. I would like to take this opportunity to thank our authors for their outstanding contributions. 

At our fall Board meeting, the AFMC will hold a symposium on the Future of Academic Medicine in Canada: The Next 75 Years. We will have speakers challenging us to consider what health care, health research and medical education will look like 75 years from now, so that we can start shaping that future. This will help inform the next phase of strategic thinking for AFMC.

Imagine: a health care system in Canada (notice I did not say 14 systems) that provides patient centered personalized care in a context supported by artificial intelligence and technology. This will be a learning health care system as defined, by the Institute of Medicine in 2015 in which, science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience. This system will be led by curious, adaptable, compassionate, collaborative and diverse health care providers focused on excellence in health and care for the populations they serve.