A CMA President who Understands Learners: Solutions to the Problems!

In this post I want to tell you a story.  It is one that talks about my values, where I put my energy and how that matters.  As I run for President Elect nominee of the CMA I hope this speaks to you.  

About four times per year I take a student or resident under my wing on a Leadership Elective registered with U of T. In December 2016 I was lucky enough to have the Chair of the Ontario Medical Students Association (OMSA), Ali Damji, join me.  You know Ali. He became a bit of a celebrity in the media last year.  In October of 2016 the OMA presented a physician services agreement to its membership at a general meeting of the membership.  At that time OMSA bravely took a stand that the profession needed to move on in its fight with government and recommended publicly that students vote to ratify the agreement.  This flew in the face of popular opinion as we now know. 

A flurry of incivility was unleashed up on him because of this stand.  In November and December, the attacks began.  Ali was bullied by physicians on social media.  He was threatened and sworn at.  He was told by more than one MD that they would personally see to it that he never got a residency position anywhere in the country.  Imagine how devastating that felt. 

Thankfully Ali was with me at that time.  He was never alone.  It was a privilege to mentor him through the decisions he had to make.  He spoke directly with the Deans of Medicine at the universities he had applied to.  He spoke to CMPA.  He spoke to the CPSO. We pulled in advocates for him.  Besides myself two strong friends, Joshua Tepper and Danielle Martin also weighed in to support him.  Ali made bold and difficult decisions.  He asked for assistance in a safe place.  And many of us were able to deliver. 

I know the pressures and issues facing medical students today.  I have lived them with you. I’m by your side when it comes to bringing the issue to light on a national stage. 

Let’s talk about the CaRMs match.  This is probably one of the most stressful things you will ever go through in your career.  So much is up in the air.  So little feels in your control.  You apply across the country to multiple programs.  You spend thousands of dollars paying for electives at medical schools to support your applications.  You fly across the country for interviews.  There are sleepless nights, constant worry, and you feel very alone in this.  Many of you will match to your first choice.  A whole bunch of you will not.  And last year 68 students did not match at all in the first round of CaRMS!  A second attempt happens in Round 2.  There, applicants are not just competing with each other, but also with immigrant IMGs who also want a chance to practice, and Canadians trained abroad looking to come home.  A few didn’t expand their selections and ended up not being re-matched. 

So what happens then?  This is a very difficult position to be in.  These students are no longer part of the medical school.  They are left to wait, and many times wait alone.  Some pursue a Master’s degree.  Others do research.  Some perform odd jobs or volunteer.  A few repeat a year of clerkship if that option is available to them.  Then they start over again with the same process. 

Unmatched students go through a period of living hell.  They feel abandoned.  They lose confidence.  Many with excellent qualifications have simply applied into small programs and not matched due to a numbers game.  They need support.  They should not lose clinical skills while waiting. They should remain a part of the educational system. 

 So much is wrong with this scenario. There are many causes contributing.   

First, medical school numbers are under the control of the University and are fairly local. The funding for those spots comes from more than one Ministry:  Advanced Education, Health and Infrastructure.  Once funding is obtained, schools are loath to decrease enrolments because their staffing, space and budgets have been arranged based on this income stream.  Numbers of medical students were increased dramatically over the past decade to meet a presumed shortfall.   

Second, post-graduate medical education positions have decreased in number.  The decisions around this are made provincially and often for political or budgetary reasons.  From what was a 1: 1.2 ratio of students to residency positions we are down to 1: 1.02, and it is predicted that this will fall to below 1:1 in the next year.  Frankly, a greater than 1:2 ratio is required to take into account immigration, transfers between programs, repatriation of Canadian students abroad and a buffer zone for variance. 

 What can be done to make change, especially by a national medical association like CMA?  The work happens through advocacy and partnership.  CMA can push for change with AFMC and the provinces. Some ideas: 

  1. The funding of undergrad medical education and post grad medical education positions needs to be calibrated.  This is not a difficult task. 
  2. A NATIONAL health human resources strategy is required that projects 8 years ahead using real data on population change, demographics, changing medical student mix, appropriate work hours, geographical distribution, and system resources.  This means working toward a common purpose with ministries of health, universities and student/resident groups to model, remodel and project. 
  3. Remove HHR planning from the provincial political realm. These are not election or partisan issues. Federally CMA can have something to say about that. I will have something to say about that. 
  4. Take a stand on ever rising medical school tuitions. Many provinces have deregulated tuition fees for professional schools. In some cases, getting an M.D. can’s see costs as high as $30,000 per year. Rising tuition leads to rising debt for many medical students. And a high debt load has the perverse effect of guiding students to choose residencies where earning potential is highest – sub specialty areas which are in low demand across the province. This increases the risk of joblessness after residency. We may have enough ophthalmologists, plastic surgeons, and cardiologists at least in our bigger cities. We need more generalists: geriatricians, psychiatrists, family doctors, internists and general surgeons. These areas pay well but cannot compete with procedure dominated specialties in our current payment model. 
  5. This could be alleviated somewhat with novel approach is to debt relief; debt repayment plans that can be incentives for generalizing. Punitive measures we have seen and provinces like Quebec should never be a choice. 
  6. Student and resident advocacy should be enhanced. You are your own best voice. Leaders in the system must allow you to step up and support your voice being heard. I want to help you expand your voice and advocacy efforts. CMA wants to do that. Your opinion matters so much because you are the future of our profession. 
  7. Support unmatched students with the opportunity to stay in practice and through educational opportunities. Keep their clinical skills up. Provide electives that give them broader reach and more exposure to other fields they may enjoy as much as what they originally applied to. Supply them with mentors that are concerned with their well-being. Give them options. 

 Advocacy issues are your issues.  I will make them mine.

If you elect to me I will supply bold physician leadership to modernize the CMA, making it an association you will want to belong to you without question. Your values are my values. I will represent you and stand up for you. I will bring your ideas forward in other very important areas as well. As CMA President I want to: 

  1. Promote a national Pharmacare platform. This can save at least $4 billion per year nationally to be reinvested in care delivery. 
  2.  Pay attention to the care of our First Nations communities. It is never acceptable that indigenous communities are without clean drinking water, being poisoned by mercury from mining tailings, or have suicide packs in groups of teens because they see no future or place in our society. 
  3. Promote the care of our military and their families who in many cases are living just above the poverty line with poor social conditions and affordability. And when returning from combat we must ensure adequate access to mental health supports to fight PTSD as well as physical injury. 
  4.  Ensure stable federal transfer payments for the provinces to support healthcare renewal. Priorities must be organized non-politically. Currently seniors care, youth mental health services and community and home care are CMA priorities and I support these. 
  5. Create a national strategy to connect patients to their healthcare providers through ongoing support of the new mandate of Canada Health Infoway. Patient access to their own data is paramount in making a making them partners in their care. 
  6. Deal assertively with taxation reform as the elephant in the room. CMA is doing its best to ensure that doctors and small businesses are not unfairly targeted, but this is only the tip of the iceberg. I believe the wholesale taxation reform is required. This should be deliberate and broad and fair. It should single out no particular group. This will take years to accomplish but must be done. 
  7.  Help modernize the CMA. Right now CMA is undergoing governance renewal. Its board is becoming smaller and more skills-based. It is going to include the patient perspective to get diverse thinking in healthcare leadership and a system that does better by all of us. Innovation is at the heart of this values-based work. A brand-new code of ethics and professionalism will soon be with us. A new CMA Charter of Shared Values is trying to express what we collectively feel and value as a profession. This is strong positive work and has been done with broad consultation.  

I am the modern broadly connected leader that can champion and promote these ideas. 

Having been on the Board of Directors of CMA’s subsidiary Joule for three years and acting before that as co-chair of its Knowledge for Practice physician advisory group, I have been part of this renewal from the start. I understand the CMA, it’s corporate structure, its limitations and potential, and its governance. I will represent physicians and the promotion of social, policy and technology innovation to assist them. I believe in partnerships to ensure the right thing happens for a for as many as possible, and in the breaking down of silos that divide and separate us. 

My leadership style is inclusive. I value and encourage different opinions to be listened to and ideas discussed openly. I am optimistic and future facing. I see medicine as an engaging career filled with joy as well as hard work. All of this gives us meaning and allows us to be the best doctors we can possibly be. Let’s lead this system together!


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