Are Canada’s medical schools failing in their purpose?

Open this photo in gallery:

James A. Dickinson is a professor in the departments of Family Medicine and Community Health Sciences at the University of Calgary. Douglas Myhre is Emeritus Professor of Family Medicine at the University of Calgary.

If you ask members of the public – or perhaps more importantly, members of provincial legislatures or the national Parliament – why they support medical schools, I am sure they would say: to produce doctors for our community. They expect enough family physicians to provide care for front-line issues in both urban and rural areas, with enough specialists to provide back up in cities both small and large.

But we all know that is not happening. Instead, new graduates from medical schools stream into crowded specialties to get jobs in major city centres. They focus on research, rather than comprehensive long-term patient care, because that provides status, high pay and positions in teaching hospitals. This has led to shortages of family physicians in the Far North, in rural towns and on Indigenous reserves. Even Lethbridge, Alta. – a university city with a population of around 100,000 – is currently desperately short.

Changing the situation would require selecting students who wanted to provide service, then training them across the range of topics in front-line medicine so that, wherever possible, the first doctor to see a patient would be able to manage more than 95 per cent of their problems, rather than referring them to specialist waiting lists. General specialists should be readily available to provide quick backup for the front-line physician. Some patients need to see subspecialists for diagnosis and management of rare conditions, but such services should also be more available close to where they live.

Most medical schools today don’t do this. The websites of most Canadian medical faculties boast about their world-leading staff, the research and donor funds they attract, and the papers they produce. These schools generally highlight their scientific innovation, and promote MD/PhD programs that lead to research careers. They do not emphasize producing graduates who will care for geriatric populations or distant communities.

There are exceptions: The websites of Dalhousie, Memorial University of Newfoundland, Sherbrooke, Northern Ontario School Of Medicine, University of Saskatchewan and the University of British Columbia. Others, such as University of Manitoba, mention community service, but only after touting their research education and opportunities. Many graduates from these schools migrate to major cities from rural areas, while few from the major city schools go in the opposite direction.

Most medical schools pay only lip service to the medical needs of rural populations, First Nations and the impoverished in cities. Some faculty members do such work out of dedication, but they are seldom supported by extra resources in the same way as laboratory research, or in the way that clinical trials are supported by pharmaceutical industry funds.

Prospective and current medical students devote their spare time to research and writing papers. They hope these will support selection into medical school and residency positions in the city-centre specialties. Spending time on deeper learning about better prescribing and patient communication, or in rural clinics and hospitals learning broad scope hands-on medical care, is not rewarded by selection committees in the same way.

Developing enough physicians to work in rural areas, or even the suburbs and small cities, is not solely the responsibility of medical schools: It also requires better systems supporting medical practice in those areas. But the medical schools influence policy and control the training programs, ensuring that their faculty are at the top of the prestige and earnings tree compared with those beyond their walls. They are affiliated with major hospitals, whose advertising through news stories about miraculous saves effectively undermines the reputation of other facilities.

People with cancer or heart disease and parents of sick children often travel many miles, bypassing their local doctors and hospitals, to get to these high-profile service providers, even when care could be done locally. The pandemic has locked people in place and substituted “virtual visits,” showing how many of these treks are unnecessary and even potentially harmful to patients.

Through their politicians, the public must hold medical schools to account and demand reform. Faculties must focus on producing physicians for underserved areas and be accountable for outcomes ­such as where their graduates practise. They must develop highly trained family physicians for rural areas and the suburbs, general specialists for mid-sized cities and peripheral city hospitals, and only enough subspecialists for actual needs. The public pays for medical schools through taxes – and we deserve a greater focus on education for service.