Bringing back rotating internships could ease Canada’s in-patient care crisis

I am writing to express my concern about what I see as a broken in-patient healthcare system and to propose some ideas on how the Royal College of Physicians and Surgeons of Canada can try to address this.I am an associate professor of surgery and surgical oncologist/general surgeon at the University of Alberta in Edmonton. I have previously served as the residency program director and the section head site lead for general surgery at my hospital (Royal Alexandra Hospital). I am currently in my second term as facility site lead for Surgery at my hospital. I have just completed three two-year terms as the chair of the surgical oncology specialty committee at the Royal College.I will start by outlining the problem in point form as I see it. After countless discussions with surgeons and other physicians in Edmonton and across the country I think many Royal College members agree with these statements:Many hospitals in large academic centers are struggling to provide adequate, safe coverage for the sickest patients in the healthcare system i.e. hospital in-patients. This is certainly the case in Alberta and I suspect across the country.PGME resident trainees are following increasingly strict rules about how long they can work, how many patients they can look after and how often they can be on call. Some subspecialties do not require their PGME trainees to do much overnight in-patient call at all (yet they are usually paid the same as residents who do lots of in-house call). As such, we can no longer rely on PGME trainees to look after all of the complex in-patients in the hospitals.The solution in Alberta, and I suspect in many other provinces, is to find “alternative care providers” to do this overnight work. In Alberta these are either clinical assistants who are usually foreign-trained doctors, or Canadian family practice physicians working as hospitalists.There are significant problems with relying on clinical assistants to do all of this night time work. They have often been trained in a different system in a different language so there is a significant amount of vetting, interviewing, and training that goes on to find appropriate people for this work. Many of these physicians are middle-aged and don’t particularly want to be doing mostly night time work and so most are only doing this work while waiting to match to a residency program via CaRMS, leading to constant turnover. The night time work is difficult and exhausting, especially for middle-aged physicians who are new to the Canadian medical system. Lastly, while we have strict limits about how many shifts our newly minted young Canadian trained PGME residents can work and how many patients we think it is “safe” for them to look after we routinely ask the clinical assistants to do three to five nighttime shifts per week looking after up to 60 in-patients. This practice seems discriminatory, borderline abusive and just plain wrong.There are two main problems with asking hospitalists to do this nighttime work. The most obvious problem is that in a time where 20% of the Canadian public cannot find a family physician (which is a national embarrassment) trying to lure more of these physicians to do in-patient hospital work seems very wrong. Even if we can find enough of these physicians, they also don’t want to be in the hospital overnight so usually only agree to work until 11 p.m. and demand to be paid a generous salary to do in-patient evening work of any sort. Those agreeing to work overnight in the hospital ask to be paid very well and who can blame them? Our system can’t afford to fix this problem by pulling more family physicians into the in-patient setting and paying them huge amounts of money.Read: Finding humanity: The lost heart of medicineOur healthcare system is in crisis. Ask any physician doing in-patient work and I think you will find most of them agree.One should never complain about a problem without proposing a solution. I propose the following solution:We once had a rotating internship system where after graduating from medical school it was expected that all MD graduates would spend a good portion of their first PGME year doing in-patient work which meant being on call, looking after sick patients and along the way learning to become better, more competent doctors.The worst thing the College of Family Physicians of Canada did was to abolish the internship system. At the time many people asked: ‘How are we going to look after all of the sick in-patients?” I’m sure there were some clever answers, solutions and ideas put forward—but clearly none of them have worked.I am tired of hearing people talk about how the “government” or “the politicians” should fix the healthcare system. It was a colossal error getting rid of the internship system and medical education leaders can show some direction and take some bold steps to fix the system they broke.While I understand that the training system for some programs 20 years ago was overly onerous and that we need to be cognizant of work-life balance for our trainees, I fear that the pendulum has swung too far . . . we are drifting into a strange new world where “hard work” is a dirty word.If we were to bring back some version of the rotating internship system we would be able to:Safely look after in-patients once again in this country without abusing foreign-trained physicians or pulling large numbers of primary care physicians into the hospital—not to mention the enormous cost savingsTrain better doctorsI am 100% convinced that if this change was announced to the students currently applying to medical school we would still fill all the spots in medical school. Some applicants might decide to withdraw their application and I would submit to you that these individuals maybe should not have become doctors.Our medical school students are a privileged, highly selected and highly motivated group of individuals. I believe that most of them go into medicine with a genuine desire to help sick patients. Their education is heavily subsidized by the taxpayers and they will go on to be extremely well paid as practising physicians. I do not think it is too much for the taxpayers of this country to ask that these trainees spend one year of their training working in the hospital looking after the sickest Canadians in the healthcare system.Dr. Dan Schiller is a surgeon in Edmonton.

Bringing back rotating internships could ease Canada’s in-patient care crisis

Register for free access or login.

Related Topics