Viewpoint

Blakeney’s views on Medical College ‘disturbing’

By Dr. Makram Boctor
MD, DMSc, FRCP(C), FACP

I am writing to you to respond to the viewpoint expressed by the Honorable Mr. Allan E. Blakeney entitled "Medical school can have unique role", published in your May 18, 2001 issue.

I found Blakeney’s comments to be both highly informative and disturbing.

Mr. Blakeney is a former Health Minister, former Premier of the Province and elder statesman of the NDP, a party that has formed the government for a substantial portion of the last 50 years and one that has had the most influence on the development of health care policy in this province. As such, it is reasonable to assume that although Mr. Blakeney’s opinions were expressed as an individual viewpoint, his views are fairly representative of the ‘prevailing wisdom’ among the policy makers in the Ministry of Health and the Saskatchewan government in general.

I am seriously concerned however by the significant misunderstanding that comes through from the Blakeney viewpoint.

To begin with there is a substantial difference between a professional school in an institution of higher learning such as a College of Medicine, and a trade school. For an institution of higher learning to fulfill its mission, it needs to be not only a place where knowledge is transmitted, but also a place where the habit of seeking knowledge for the rest of ones professional life is fostered and instilled. The only way that we know of for doing this, is the provision of an environment where knowledge is not only transmitted but new knowledge is discovered. This is the reason accrediting bodies have looked at the scientific environment in an institution as one of the three pillars on which such an institution is built, mainly education service and research. I may add that the ‘trade school’ model of a medical school ceased to exist as a consequence of the 1910 Flexner Report. It is thanks to this reform in medical education that North American medicine has achieved the quality it has. The respect which it has garnered by being based on an academic model combining the human values of medicine and the rigor of science, not just "here, this is what I do", has moved North American medicine from one of the poorest examples of medical practice to currently the highest.

Mr. Blakeney talks about the training of medical practitioners for "standard" medical practices around Saskatchewan. This is not the mission of a medical school. The mission of a medical school is to train the undifferentiated health care professionals who at the end of their years of medical study, and after the MD program, are now fit to embark on the new training that will qualify them for whatever career they may choose in medicine, be that Family Medicine/Primary Care, specialized medicine, regardless of the specialty, or indeed research and yes in the human genome project. The utilitarian model that Mr. Blakeney envisages was tried in two notable experiments, namely Russia after the Communist Revolution of 1917 and French Indochina. The experience of rushing through the assembly line a large number of rural and "standard" practitioners to make up for the huge numbers of physicians that were either killed or escaped after the revolution resulted in the production of substandard practitioners who, while they did fill a role in the early days, were found to be highly defective and were replaced as soon as conditions stabilized. The experience with the medecins indochine in Indochina was part of the colonial past of these countries which basically felt that the average population did not deserve or could not be expected to benefit from standard quality western medicine. Surely our population deserves better.

Mr. Blakeney goes on to define the new service mission for the college. When it was first installed it was to provide the specialized services that Saskatchewan needed at a price that was significantly cheaper than sending our people out of the province to get the same services. As such, the college was responsible for recruiting a large number of ‘first of a kind’ for Saskatchewan. The mission is to be totally changed. Somehow the college has to now take charge of provision of health care for rural remote and Aboriginal communities. While these are very noble goals, they are part and parcel of the mission of the ministry of health. The college cannot be expected to hire the hundreds of practitioners for all of these missions; neither is it appropriate to consider the college as the paymaster for physicians that have nothing to do with educational mission of the college, as had happened earlier. Not only is that peripheral to the college’s mission but it distorts the picture and presents an image of a much higher level of funding for what has nothing to do with the core academic mission of the college, indeed even with the peripheral academic mission of the college. I do feel flattered as a member of the faculty of the college that Mr. Blakeney now thinks that this should be handled by the college since this daunting task has proven to be beyond the abilities of every other body that has attempted it so far. My question however returns to what has that got to do with being a College of Medicine? The other question is how quickly does Mr. Blakeney expect the College of Medicine to do a 180-degree turn with a total change of mission as dictated by the political imperatives of the day, worthy as they may be. What would be the next convulsive change in the service mission of the college from being a highly specialized institution providing tertiary care to being the only means of getting the providers of health care in remote and rural communities? To what extent and where do the medical students and residents fit in all of that?

Mr. Blakeney lists the previous scientific accomplishments in Saskatchewan, namely the Kidney Transplantation and the Cobalt Bomb. The Kidney Transplantation Program was started by Marc Baltzan without the college being involved to begin with, and was continued by him in spite of all the obstacles and blocks. It is really a tribute to the man’s spirit of persistence and dedication. The Cobalt Bomb is no different. Again it was an individual effort that had nothing to do with the Saskatchewan Government, the College of Medicine or their agencies. People did it on their own time and with limited resources. It is quite evident that in this day of total control, any such innovation would be impossible, for it would not be allowed. Not only would the capital funds be denied but the operating funds would also be deferred, delayed or studied into extinction. The examples where we have been the last abound: The last medical school to have a CT scanner and the last province to have what is a barely sufficient number of CT scanners, the last with an MRI, the province with the lowest availability of bone densitometry, and so on and so on. This is today’s environment. How one would expect trailblazing innovation to come out of that, I do not know. My point however is the system should not claim credit for what it did not foster or generate and that credit should be given where it is due.

While I agree that Saskatchewan has one of the smaller population bases to support a medical school, the credit of being the smallest goes to Memorial University, which is supported by Newfoundland and Labrador. However that would be hair-splitting and quibbling over minor details. The fact of the matter though is our medical school has had the lowest ability to obtain outside research funding of any of the 16 medical schools in Canada, as a direct consequence of the policy of denial of funds for research, severe underfunding and under-staffing, with clinical and teaching workloads that leave no room for research. It is this reality that has led Drs. Yager and Pierson to express their frustration and apprehension.

Mr. Blakeney goes on to cite the human genome project as an example of those unrealistic pie-in-the-sky type of things that we should learn to live without. I would like to remind Mr. Blakeney that, among others, the human genome project is about counseling the parents of a child with a genetic disease about how to care for their child as well as about future pregnancies, it is about making an early diagnosis of familial diseases, and deciding whom to follow and whom to not follow, both of which bring about significant savings to the public purse. Other applications of the human genome project include the establishment of paternity, and DNA testing to find innocence or guilt. Indeed to not be involved in the ‘human genome project’ would be a gross disservice not only to the medical interests but to the law enforcement system in Saskatchewan. I am afraid as such it was probably a poorly picked example.

Drs. Pierson and Yager raised some very germane questions, namely: can Saskatchewan afford to have a medical school, and if so, is it willing to fund it appropriately because the future of the medical school is threatened.

Unfortunately Mr. Blakeney’s answer is very enlightening but also threatening. Mr. Blakeney seems to say that we do not want to have a real medical school, what we want is a trade school that produces some kind of practitioners to be defined by what the political masters want for that day. Forget about any dreams of having appropriate staffing, funding or research facilities. Do what your political masters say and then we will decide on how much money you may get. "With such a mandate, the financial resources required by the College of Medicine could be greater or less than now envisaged." Knowing the economic climate of the last several years, what Mr. Blakeney seems to be saying is count your lucky stars you have any money. It can only get worse. Do not compare yourselves to other medical schools for you are not really a medical school in the academic tradition but a trade school with a service mission to be defined for you and changed whichever way we see fit.

I shall return to my starting point – namely that Mr. Blakeney’s views are probably an expression of the prevailing wisdom that has guided policy towards the University and the College of Medicine in particular. Is it any wonder that we are in the mess we are in?

Dr. Boctor is Professor and Head of the U of S Department of Medicine’s Division of Endocrinology and Metabolism.