NB med school top of its class

It may just be a year old, but New Brunswick’s medical school already has some of the most advanced technology on the continent. Or at least they’re using it in a most advanced fashion.

As per the usual classroom setting, a professor delivers a lecture and students take notes, ask questions which the professor then tries to answer. The thing is, more than 400 kilometres separate pupil and teacher.

The school is being hosted at the University of New Brunswick’s Saint John campus, but is actually an expansion of the medical school in Halifax, and is formally called Dalhousie Medicine New Brunswick. The goal is to give New Brunswick students an opportunity to learn medicine in their own province, but without sacrificing quality of education. By using the high-definition video-conferencing equipment, students get the exact same education as their colleagues in Nova Scotia.

And now they’ve installed the equipment at four hospitals across the province so students completing their clerkship can be equally linked to their peers.

“It’s just a real tremendous improvement,” Pamela Bourque, Dalhousie Medicine New Brunswick’s program manager, said of the new installations, which took place in June. The four hospitals are located in Saint John, Fredericton, Miramichi and Moncton.

Each video-conferencing classroom is identical, with grey walls and light grey wall-hangings, medium brown tables, pleasant lighting and carpets with a grey-toned, geometric design. This way, the two parties feel more like they’re in the same room. At the front of the room are three large flat screens. During class, one displays the professor, the second the material, and the third screen shows the other students sitting in Halifax.

Sheldon Wood is going into his second year – or M2 – at the Saint John location. After next year, Wood will start his clerkship at a New Brunswick hospital, where he will be able to take advantage of the new equipment expansion. He admits that he was at first skeptical about not having the professor in front of him, but said he didn’t notice a difference. He said there is no noticeable time gap between a student asking a question in Saint John and a professor responding in Halifax – the broadcast transmission is that instantaneous.

The professor can even see the student, thanks to a table buzzer. There’s one for every two student seats, and when pressed, a camera at the front of the room swivels to point there and the student appears on the screen in front of the professor.

Representatives from other medical schools across the country have already visited Saint John to see and possibly copy the set-up. Ken Lerette is the technical operations manager at Dalhousie Medicine New Brunswick and said they’ve given tours to representatives from the University of Toronto and even Saudi Arabia.

The pilot year passed virtually flawlessly, Bourque said. She estimates that if you added up all the time that was used to fix technological problems, they probably only lost about 17 minutes of class time, over five incidents. Two impressive, futuristic central command centres in Saint John and Halifax handle all the troubleshooting and maintenance.

While similar video-conferencing equipment has been used for long-distance education, this is the most advanced system for medical education.

Previously published July 25, 2011; Telegraph-Journal

To mandatory nap or not to mandatory nap

It’s safe to conclude that most people would not take issue with a requirement that they take a nap at some point during their workday. The United States Institute of Medicine even urges that a five-hour snooze should be made mandatory for all medical interns and residents who are putting in 16-hour shifts.

The Canadian Association of Interns and Residents, though, isn’t convinced of the value of mandatory naps. In fact, Executive Director Cheryl Pellerin says that if naps are added into contracts, they could interfere with a resident’s training — he or she might miss a procedure vital to a good education.

Mandatory naps are among options being bandied about in response to growing concerns that lengthy shifts for interns and residents compromises the safety of patients. While many jurisdictions are still exploring alternatives, the European Union has adopted a maximum 48-hour workweek as its solution to the problem (CMAJ 2009. DOI:1503/cmaj.109-3111).

The US Institute of Medicine waded into the debate with a recommendation that every resident or intern should be obliged to nap for five hours — at some point between 10 pm and 8 am — for every 16 hours they work. During the nap, there should be no interruptions or pages, the institute says in its report,Resident Duty Hours: Enhancing Sleep, Supervision, and Safety(http://books.nap.edu/openbook.php?record_id=12508).

While interns and residents in Europe are now limited to 48 hours of work per week, the situation in the US and Canada is less stringent. In 2003, the Accreditation Council for Graduate Medical Education capped the hours a US intern or resident could work at an average of 80 hours per week over four weeks. In Canada, while regulations vary from province to province, an intern or resident generally works no more than 60 to 80 hours per week. Only three provinces have maximum weekly hours built into their legal contracts; Manitoba’s regulations are the highest at 79 hours.

Mandatory naps would be “kind of difficult to institute,” says Dr. Roona Sinha, past president of the Canadian Association of Interns and Residents. “What matters more is trying to make the person functional the day after.”

Shorter shifts and more rest hours after long shifts would be preferable to mandatory naps, Sinha adds.

Pellerin concurs, saying that more effective handovers of patients as shifts change would be more significant that midshift naps. An association working committee on postgraduate medical education is currently investigating the best ways to structure handovers so that the incoming physician or resident is well informed about the patient, so that fewer mistakes are made. That review is expected to be completed early this year. While most of the concern about lengthy working hours has been focused on interns and residents, some say the scope of concern must be extended to include all physicians and surgeons.

People are wary about limiting the hours worked by physicians and surgeons but it’s something that needs to be addressed, says Dr. Derek Puddester, director of the faculty wellness program at the University of Ottawa and coeditor of the Royal College of Physicians and Surgeons of Canada’s CanMEDS Physician Health Guide.

Younger physicians aren’t inclined to toil as many hours as their older counterparts, Puddester says, adding that the younger generation has been socialized to value work–life balance, so as they move up and become practising physicians, that ethic will likely be a condition of employment. As a consequence, he predicts limits on weekly work hours will be introduced within the next five to seven years for most doctors.

Cheryl Ulmer, coeditor of the Institute of Medicine report, concurs. “Doctors are human too,” she says.

But others, such as Dr. Thomas Nasca, chief executive officer for the Accrediation Council for Graduate Medical Education, says capping work hours or introducing mandatory naps for physicians and surgeons isn’t feasible. “Who’s going to take care of the patients while we’re sleeping?”

Nasca adds that the cost would be prohibitive, citing a study that indicates it would cost roughly US$80 billion per year to train the physicians that would be needed if doctors adopted the work-week standards of airline pilots (Am J Surg. 2009;197[6]:820–5). And that doesn’t take into account the notion of continuity, which is integral to effective patient care, he says.

When the Accreditation Council for Graduate Medical Education implemented an 80-hour work week limit for interns and residents in 2003, it promised a review of the guideline after five years.

The results of that review, which included a national duty hours congress, independent literature reviews and consultations with over 140 medical organizations, will be presented in February, Nasca says.

Thus far, it’s clear from the review that the number of duty hours and nap times aren’t as crucial as top-notch supervision, Nasca adds. “This is not an issue of right or wrong, it’s an issue of competing goods.”

First published Jan. 5, 2010; Canadian Medical Association Journal

Is there life after medicine?

For some, retirement is a relief — rounds of golf interspersed with naps and other luxuries like the time to read a novel.

Others miss the camaraderie of the workplace and the sense of purpose their careers provided.

Doctors are no exception in either category, says retiree Dr. Ashok Muzumdar. “I find some physicians, males and females, do not quite enjoy their life to the fullest after retirement. It’s like falling off a cliff. They’re finished practicing medicine, now what?”

In a bid to help those who might fall within that latter category, Muzumdar is spearheading the development of a Canadian Society of Retired Physicians which might serve a variety of purposes, including a vehicle for mentoring, a forum to exchange ideas and concerns about the changing medical landscape, and even social gatherings.

Muzumdar says he’s now canvassing Canada’s estimated 9000 retired physicians to see if they might be interested in forming the Canadian equivalent of the United Kingdom’s Retired Fellows Society, (a section of the Royal Society of Medicine).

The UK society, now in its 12th year of operation, serves as an excellent vehicle for retirees to keep in touch with one another, writes Dr. Pat Last, past immediate chairman, in an email. “Once retired, one’s interest in the current medical scene wanes and one is more interested in keeping touch with colleagues.”

To that end, the Royal Fellows Society organizes lecture luncheons and outings focused on an eclectic variety of topics within medicine, science, history and the arts.

Muzumdar hopes that a Canadian society might serve a similar social purpose, while also providing a vehicle for retirees who’d like to keep making a contribution to Canadian health care, by say, mentoring residents or young physicians, or becoming involved in policy development.

Canada’s geography is an obstacle, Muzumdar admits. The 1200 members of the UK society are concentrated in an area approximately 40 times smaller than Canada, and even distant members can readily attend luncheon gatherings.

But the problem of distance isn’t insurmountable, says Dr. Eugene Nurse, acting chair for the senior and retired doctors section within Doctors Nova Scotia, the only organized body in Canada for retired physicians.

“It’s amazing that we don’t have [a national association] already,” Nurse says. “The British have one, and goodness, we take everything we have from the Brits!”

It’s hoped that some of the geographic obstacles can be overcome through the use of information technologies and to that end, Muzumdar is working with John Feeley, director, members and provincial territorial medical associations, in the Canadian Medical Association’s department of community building, to explore how the Internet might be used to expand awareness of the embryonic effort to create a national association of retired physicians.

The problem, Muzumdar says, is that many retired physicians of his generation aren’t altogether familiar with electronic tools. Nurse says that during the Nova Scotia association’s formative years, traditional (standard mail, rather than email) communication methodologies had to be used to get the word out to some. But once word spread, the response was enthusiastic, he says.

Muzumdar says that before officially launching an association, he hopes to attract a base group of 50–60 retirees who can help with the spadework, including fleshing out the range of activities it might offer: mentoring of younger physicians, reading clubs, golf or travel clubs.

The value of, and need for, a retirees association will become ever greater as the baby boom generation retires, Mumzumdar says, adding that it would be a waste for society to turn their backs on a resource that isn’t now being used to its potential. “I’m just one among thousands who could be very useful to different facets of post retirement life,” he adds.

First published Dec. 13, 2010; Canadian Medical Association Journal

One-stop shopping for international medical graduates

International medical graduates will be entitled to apply for a medical licence simultaneously in all provinces under a new national electronic application process that will come into effect in 2012.

The initiative will further streamline and simplify the foreign credentialing process by building on a central electronic repository that was established a few years ago to house information from international medical graduates (IMGs) seeking to work in Canada.

In addition to all but eliminating paper-caused confusion, it will be a “one-stop shop” for IMGs, says Dr. Ian Bowmer, executive director of the Medical Council of Canada. As the application will be online, “it will be more transparent and everybody will know what is required. You won’t have to go to 13 different websites to find out.”

The Medical Council of Canada-and the Federation of Medical Regulatory Authorities of Canada-led initiative is being undertaken with the aid of a $2.8 million contribution from Human Resources and Skills Development Canada’s Foreign Credential Recognition Program.

Currently, physicians must complete a different application for each province or territory to obtain a licence to practise within that jurisdiction. But once this national process comes into effect in late 2012, the same form will be used to apply to multiple regulatory authorities.

License applications to a province will include online access to an applicant’s resumés, which will be housed in the Medical Council of Canada’s Physician Credentials Repository.

An application will also include information about examinations and certifications required by a particular provincial licensing body, so IMGs can readily determine whether applications contain all the requisite components.

The new process will not replace the Medical Council of Canada evaluating exam or two-part qualifying exam needed to obtain a licentiate from the council — a prerequisite for Canadian licensure — and each province and territory will still control its own requirements for awarding full certification.

Nor will it reduce the significant expenses that IMGs incur to become licensed. For example, taking the evaluative exam alone costs $1500.

“The savings for IMGs coming to Canada will be through more simplicity, more understanding of the system,” says Dr. Bill Lowe, president of the Federation of Medical Regulatory Authorities of Canada.

Lowe adds that it’s hoped over the course of the coming two and a half years, regulatory authorities from each of the provinces and territories will be able to collaboratively produce a pan-Canadian application process for medical licensure which will satisfy all the licensing bodies.

But while some internationally-trained physicians say that creating a simpler application process would be “great,” they suggest that the monies might be better spent on creating more positions for IMGs. An IMG has fewer opportunities to become an intern or get a job because most positions are set aside for graduates of Canadian medical schools, says Dr. Monica Herrera, president of the Association of International Medical Doctors of British Columbia.

“Right now, it doesn’t matter how much you try, doesn’t matter if you pass everything, you may not get it at the end,” says Herrera, who was born in Chile and practised many years in Colombia before immigrating to Canada in 2003.

While the initial goal of the initiative is to simplify the application process for internationally-trained physicians, Lowe says the long-term objective is to make it easier for physicians to obtain their licences in other provinces and territories.

When the Federation of Medical Regulatory Authorities of Canada and its members became aware that some sections of a soon-to-be-finalized agreement on interprovincial trade would enable licensed physicians to relocate in other provinces or territories without further examination or assessment, they realized they needed a consensus on qualifications for pan-Canadian medical licensure, Lowe explains.

Another added benefit is that the Medical Council of Canada’s credential repository will eliminate the need to repeatedly supply original documents, Lowe says, recalling the case of one doctor who had to bring in his coffee table to Nova Scotia authorities to verify his medical certificate because he’d laminated the document to its surface.

First published Sept. 13, 2010; Canadian Medical Association Journal