Time for a new approach on training doctors

DR. DAVID LARGE GUEST OPINION Dr. David Large lives in Port Joli.



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For a couple of decades, I have observed the gradual changes that have crept into the practice of family medicine to replace what was always known as “general practice.” The change started when the College of Family Practice decreed that the training of family doctors was better accomplished by eliminating the traditional rotating hospital-based internship and creating a specialty CCFP family doctor trained for two years largely in a university setting. Universities and governments gradually embraced the opportunity to train family doctors by academic-based physicians for two years, eliminating the old hospital-based system of one-year internships. The emphasis changed from meeting the daily triage of emergent, urgent and elective situations in an effective and timely fashion to a more multifocal approach that doesn’t seem to factor in community needs and productivity. It used to be that every citizen in any community was covered by a medical practitioner and functioning on-call system in all towns and all hospitals. Physicians worked to meet the daily demands and infrequently, when overwhelmed, would reach out for temporary help from a colleague. There were evening office hours every weekday in towns for those urgent cases that arose after hours and staffed emergency departments for emergent cases. Rural single physicians would define their off hours and refer to open offices in adjacent towns. There were never daily eight-, 10- or 12hour waits in standing roomonly emergency departments filled with all levels of need, elective to emergent. I applaud Dr. David Howe, who succinctly outlined the problem in his April 25 letter in The Chronicle Herald, “Paradigm shift needed in family practice.” His paradigm shift really should have the government define and evaluate the community needs for medical care around the province, and challenge Doctors Nova Scotia and Dalhousie Medicine to address the shortcomings. It used to be possible, with available resources and appropriate emphasis on full coverage and productivity, to meet all needs. Thousands of general practitioners who trained in the crucible of a year-long rotating internship learned the skills of doing the right workup and therapy in a timely fashion to present their cases at grand rounds in the morning. After that year, time management of a 3,000 person-caseload and 25 to 35 patients a day came easy. Two decades of annual health budget increases, and replacement of the retired old guard with fresh graduates, has not kept pace with traditional needs. These two decades have been too long a time to ignore the festering canker of unmet community concerns. We have seen that throwing money at the problem has not worked. A new approach involving problem defining and solving, including representatives from communities, experienced retired practitioners, training personnel, existing providers and government paymasters, planners, and politicians, is needed to address workable solutions. We have one of the costliest health-care systems in Canada. It should not cost a fortune to fix it so it works for us. It’s time for a robust focus on meeting the serious unmet needs of our underserved, ailing population. After this, we need to streamline hospital service to maximize productivity there.