OHIP Decision

This article in the Globe and Mail indicates an interesting change in how OHIP may be delivered and how it's payment may be considered.

"More broadly, the case suggests Canadians should be savvier before going under the knife, asking doctors how many of a given operation they have performed, and their death and complication rates. It also raises a delicate debate: How many operations does a surgeon have to perform to be considered proficient?"

When you consider several factors, including Malcolm Gladwell's Ten Thousand Hour Theory it's hard to imagine how medical students and physicians ever see enough of a specific pathology to master it. (In case you are unfamiliar with this theory, it essentially states that to truly be the master of *something*, you need to have practiced it for 10, 000 hours. Essentially four hours a day for ten years.)

Medications and imaging reduce the severity of many pathologies we may normally see. Speaking with residents and consultants, it seems that 10 years ago putting in chest tubes and draining abdominal ascites were procedures often done.

Now though I can honestly say I've seen 2 abdominal ascites drained and 2 chest tubes placed (both on the same patient). I would not be able to perform one myself if the need arises, but now that I've finished the rotations in clerkship where I might see one, I have to hope that when residency rolls around I'll have another chance.

Something as uncommonly seen as this cavernous brain stem tumour would be difficult to master based on number of cases alone, though interesting that the American surgeon managed to amass 200 cases. Would virtual cases or those practiced on animal models count to one's mastery?

What is most concerning about the principle behind this ruling in favour of Brad's family is that if everyone decides to only be treated by the very best, those of us training to do our best are unable to learn. When the specialists retire, the patients will have set up a situation with no one to care for them.

Clearly this is taking it to the extreme, but I think the point is still valid. Medical trainees need to learn on real patients. Patients deserve the best care. These two factors do not need to be mutually exclusive and we see that in academic hospitals.

When trainees are in the OR with their consultants, the trainee does the majority of the surgery while the consultant assists. The consultant is there if the trainee needs help and to offer advice about unusual findings during the procedures. The patient gets the care of several surgeons, often two anesthesiologists and 2-3 nurses during their surgery. The trainees have read about the case and the pathology and are up on the latest findings (unless they are terrible trainees, but that's another story).

I'd feel safe in a training hospital.

But I'm still stuck on what it will take for me to be a great family doc. Our residency is only 2 years. I feel like I haven't been studying enough to be on top of everything I'm supposed to know for clerkship let alone residency. Getting my 10, 000 hours in is going to be a challenge.

Currently, I'm in the hospital on the weekend, taking an extra call shift in the hopes of seeing a new pathology I haven't seen before. I know that I learn by seeing and doing and that I can't do this from home.