Health Committee on Feb. 5th, 2013

[The Chair, Conservative, Joy Smith]

Thank you so much, Dr. Gold and everyone who has participated in this.

We'll now go to Mr. Lizon.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

Thank you to all the witnesses for coming here this afternoon.

My first question is for Dr. Jalali.

Going back to the new methods of teaching, how would you say they compare to those in other places in the world? Are they changing and going in the same directions? The other part of the question I would like to ask is, if someone decided to stay and do traditional teaching, would you say that the results would be different? Would you assess a graduate from one university and one from another as being on the same level, or would there be a disparity? What are your views on that?

[Dr. Alireza Jalali]

Actually, this is an interesting question, because I actually did my MD degree in Belgium, and I did my specialty in France, so I can clearly compare Europe to here. I'm Iranian in origin, so I've been to Iran. I have seen what's happening.

The medical education in North America is evidence-based, so they go with what evidence shows to be working in educating people, whereas in Europe and in other parts of the world maybe it's more traditional. So you will see in many European countries that they still do lots of lectures whereas here we don't. We don't do that here because not only are we evidence-based, but also it has been shown that active learning creates a long-time memory. What is the problem doctors have? They do medical education; then they do residency; and then they're out, and you have them for 20 years, 30 years after and they still need to remember this stuff. So you want long term and you want them to be independent, and the AFMC has actually done a very good job at accrediting.

When you ask if someone can do lectures all the time in Canada, they can't. They can't in the U.S. either, as the lecture hours have been cut because it has been shown that small-group teaching active learning is much more proficient in the long term. All these are evidence-based in active learning, in actually how adults like to learn. We always consider our students to be adults so we know they're motivated. We know they want to learn, so we give them all the tools and make them learn how to learn this stuff. As the information changes, what I tell them now on how to treat hypertension maybe in 20 years will not be the way. They need to be able to find it out.

Do you want to add anything?

[Irving Gold]

I would concur with everything that was said.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

Going back to the future planning and shortage of doctors in certain specialties, do you have anything in place now that would do early streamlining? As you heard here, you can't force anybody to enter a certain specialty, but do you streamline students? Let's say you have 10 places for surgeons, but you would have 20 or 30 at some point for geriatrics. How do you do it on your side?

[Steve Slade]

I think it's done jurisdictionally.

In Quebec, for instance, there is a venue in which the provincial government sits down at the same table with the faculties of medicine and with hospitals, and they look at expected vacancies. They actually look at the number of surgeons expected to retire at the hospitals in the jurisdiction, and they allocate their residency quota accordingly.

Ontario has quite an elaborate model. They've tried to look at the data in a more robust way, weighing it against expected changes in the population, and again that table exists at which the provincial government sits down with the faculties of medicine and they make decisions about what the quota will look like.

So, again, I would repeat the point about the system-wide approach to this. There are more residency positions in geriatric medicine than are filled by residents. Graduating medical students are looking at that specialty and they're making decisions based on whether they would be doing a lot of on-call, whether they are going to be paid in a way that they want to be, whether they will have opportunities to teach and do research. I think there's a bit of a package that has to be looked at.

[The Chair, Conservative, Joy Smith]

You only have about 30 seconds left.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

A quick question is, how do you fit in all of these foreign-trained doctors? That includes young Canadians who go abroad and immigrants who come in.

[Irving Gold]

All I can say is, that's not a quick question. We could have an entire day-long conversation—

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

I asked quickly, but—

[Irving Gold]

It is a big issue and one that I could not possibly do justice to in a short comment.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

But maybe you can provide the committee with some kind of comment later.

[Irving Gold]

I'd be happy to.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

It would be appreciated. Thank you.

[The Chair, Conservative, Joy Smith]

Thank you so much, and now we'll go to Dr. Fry.

[Hedy Fry, Liberal, Vancouver Centre, BC]

I had a quick question. I'm not trying to cause trouble, although that is not something I shy away from, but you were talking about how long this has been going on. I remember chairing a Canadian Medical Association committee in 1987 that talked about the fact that we were going to need primary care obstetricians—well, primary care people to do low- and medium-risk obstetrics.

Well, because everybody was 55, new people weren't coming into that. They didn't want it, and we've been trying since then. Nothing's happened, and we now have the problem that we don't have anybody doing primary obstetrics; we're just going to have to go straight to specialists.

I think the thing about it is it costs the system a lot more money to pay an obstetrician to deliver a low- or medium-risk baby and then for a pediatrician to do the well-baby care, which could be done in some places by nurse practitioners or by family physicians, but nobody wants to go into that.

So this is not simply a case of saying let's get a mix, let's pay off your students loans, let's help you with monetary incentives, and let's look at the disincentives.

How do you actually get groups of physicians to want to go into the labour-intensive, long hours of certain specialties that require that? You think you've just worked a long day, and the next thing it's three o'clock in the morning, and you get called out to deliver a baby, or your kid has a piano recital, and you're going out to deliver a baby. So people don't want to do it anymore because their lifestyles aren't doing it.

There has to be a solution to that, not simply financial or whatever; it's a lifestyle thing. Have you any suggestions for that?

[Steve Slade]

In terms of answers, sorry if I'm going to shy away from it, but I think the problems or the issues are complex. For instance, right now there are efforts under way in various jurisdictions to look at resident duty hours, the amount of time that is allowable to have a resident doing a shift, and this exacerbates the problem, to some extent.

That said, for instance in Quebec, there are some very elegant solutions to this problem in terms of looking at how the hand-offs work, the transitions from one shift to the next, and how to readjust the schedule. The point I would make is that I think there are successes and solutions that are happening at a very local level.

McGill has looked at how they're going to adjust their resident shifts in internal medicine to address the fact that they can only have residents working for a maximum of 16 hours. I would look to those examples—

[Hedy Fry, Liberal, Vancouver Centre, BC]

That's for training only. I'm talking about getting people to go into it so that they can go out there in the community and practise that kind of stuff. People don't even want to go into it, never mind during the residency.

I also wanted to point to.... The troublemaking piece was that during the 2004 accord, HHR was specifically deemed by the premiers of the provinces to be a co-jurisdictional thing. The federal government co-chaired and British Columbia, if I recall rightly, was the province co-chairing it, and they were to come up with a pan-Canadian HHR strategy looking at supply and demand, and the federal government would play its role, and the provinces would play their role. It was coordinating to get jurisdictions. Why did that not ever happen? After 2006, nothing happened.

[Irving Gold]

I wish I could explain why these things don't happen.

[Hedy Fry, Liberal, Vancouver Centre, BC]

That was a rhetorical question actually.

[Voices]

Oh, oh!

[Irving Gold]

I know. I wish I could explain.

With respect to your first comment, the only thing I would say is, I think that in all of these discussions what we need to be putting first and foremost are the needs of Canadians. Those are what we should be using as the organizing principle for our health care systems across the country and for any national approach to HHR planning.

Finding incentives and disincentives, sure, that is a subtext, but what we need to understand is what the needs of our population are, and that should guide us.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Fry—

[Hedy Fry, Liberal, Vancouver Centre, BC]

Did I have any seconds left?

[The Chair, Conservative, Joy Smith]

Sorry, no.