New legislation will allow control of medical treatment

By David South

Today’s Seniors (Canada), December 1993

It isn’t the nicest thing to think about, but if accident or illness strikes, you could end up receiving unwanted treatment. 

But in 1994 things will change. The living will or advance directive - a document clearly stating a patient’s wishes about how they want to be treated - will become part of the doctor-patient relationship. 

A trio of acts passed last December - the Advocacy Act, the Substitute Decisions Act and the Consent to Treatment Act - allow, albeit in rather vague language, for Ontarians to set out in advance which medical procedures they would or wouldn’t accept and let’s them name a proxy in case they are incapable of expressing their wishes. 

This vague language - intended to allow patients to customize their wishes - means that writing a living will can prove to be a troubling and confusing experience. 

To aid decision-making, the University of Toronto Centre for Bioethics is offering advice through a “model” living will. 

The centre’s Dr. Peter Singer has geared the “model” to meet Ontario legislation and to offer a guide for anybody who doesn’t know where to begin. 

“We put a lot of detail in the advance directive about states of incompetence people get into, and also the sorts of procedures providers might recommend in those health states.”

Singer sees living wills as an effective tool aiding patients to control their own health care.

“Unless the doctor is a longstanding friend it’s hard to know what patients want. As a practicing doctor, I have run into an incompetent person where their family member has no idea what sort of wishes the person would have wanted. The goal of a living will is to provide the personal care the patient would want.”

But there is a danger. Dr. Singer urges the need for informed and detailed language in a living will. 

“If I have a couple minutes to make a decision I need a document that gives me a lot of confidence that this person wouldn’t want this treatment.”

In an emergency, the doctor might not even know of the living will’s existence. Dr. Singer advises giving a copy to your family doctor, lawyer, or proxy, and keep one with you at all times. When so-called “smart” health cards come along, Dr. Singer would like to see the living will recorded on the magnetic strip along with other health information. 

Land of the Free, Home of the Bored

Underwhelmed by Bill Clinton’s Democrats

By Nate Hendley and David South

Id Magazine (Canada), November 14 – 27, 1996

Toronto – It’s Tuesday, November 5 – American election night. A crisp autumn evening greets our search for the political philosophy buried in the US Democratic Party. Is it really the liberal heart of the United States as legend has it, or is it, as critics charge, a carbon copy of the arch-rival Republicans?

Inside the University of Toronto Women’s Club, the 80s chintz has given way to stars and stripes. A broad-mouthed woman with a bright red suit jacket and big, blonde hair greets the arrivals to the election party sponsored by Democrats Abroad, a group of expatriate American citizens living in Canada. Flags hang from the ceiling, political posters and Clinton/Gore in ’96 buttons are scattered throughout the club’s rooms. The dull cocktail party ambience contrasts with tonight’s occasion: a victory party to celebrate the rare re-election of a Democratic president. The wealthy looking and nearly all-white supporters of the Toronto chapter of Democrats Abroad – the organization boasts 600 members Canada-wide – spend the evening sipping wine and politely cheering as election results flash on three TV screens.

The tepid atmosphere is subdued in the extreme: nobody gives out war whoops, dances on tables or misbehaves as the election results trickle in. The reaction to Clinton’s win reflects a tepid Democratic campaign notable for conservative proposals, silly promises and an abandonment of the kind of liberalism the Democrats once stood for.

Conservative Clinton

Clinton’s enemies might accuse him of being a leftist, but in truth he’s been one of the most conservative Democrats to occupy the White House this century. Clinton’s less-than-liberal achievements in his first term include more crimes punishable by the death penalty, a promised additional 100,000 police on the streets, “V-Chip” technology in television sets, an intensification of the war on drugs and an abandonment of federal responsibility for welfare. Clinton’s re-election campaign featured promises to encourage school kids to wear uniforms, a vow to get even tougher on drug use by such measures as forcing teenagers to pass urine tests before issuing them driver’s licenses, and a recommitment to eliminating the US federal deficit.

The mostly monied professionals at the party are well aware of Clinton’s rightward turn since taking office in 1992, but put the president’s conservative leanings down to pragmatic politics.

“Am I disappointed in Clinton?” asks Bill Cronau, the past chair of Democrats Abroad and self-professed liberal. “Sure, but I’m not surprised that Clinton became more conservative. He is a Southerner after all.”

Arkansas-born Clinton used law and order issues “to chop GOP off,” adds Cronau, an insurance manager for Manulife, on the president’s theft of the Republican’s thunder.

The closest thing at the party to an actual living American politician is Tom Ward. Ward, with a detached air and the glow of a politician, soon attracted an audience when he entered the room. Ward twice ran unsuccessfully to become a Democratic congressman for Indiana, and agrees that overall Clinton has been “a disappointment as a liberal.”

He also agrees the president has moved far more to the right than previous Democratic presidents such as Jimmy Carter or Lyndon Johnson. Still, Ward, who has lived in East York since 1989, gives Clinton liberal kudos for his attempted passage of health care reforms. Yet Clinton’s proposed health care plan fell apart in 1994 following intense debate and criticism from the Republicans. Ward says he would try to introduce Canadian political ideas such as universal health care and stricter gun control were he to return to Indiana for a third run at Congress.

Canada or Clinton?

Joan Sumner, a psychologist originally from New York City, says she was initially impressed by Canada’s health care system, and by Clinton’s attempt at passing similar legislation in the US. But now she’s having second thoughts.

The Republicans, under Ronald Reagan and George Bush “decimated the health care system in the United States,” she says. “To run a medical practice became like running a business. It became difficult to collect from the insurance companies, who were reluctant to pay for psychiatric care.”

Sumner, who works with people who have “closed-head injuries,” has lived in Canada for 11 years. At the time she arrived, she found Canada’s health care system in good shape. “Now it’s a disaster and going from bad to worse. Truth be told, I am thinking of looking back across the border, especially with Clinton’s second term. The federal Liberals and the provincial government have no commitment to the people of Ontario.”

She complains about the extent of America’s influence on the Canadian political system.

Mike Harris, she fears, is borrowing his ideas from conservative Republican governor Christine Todd Williams in New Jersey. She would prefer Harris to look to liberals like former New York governor Mario Cuomo for inspiration. Unfortunately, Cuomo’s version of liberalism is out of fashion in both Canada and the United States these days.

While nearly everyone at the party expresses displeasure with Clinton’s turn to the right, few can explain why they supported him over his Republican challenger, Bob Dole.

In one corner is a bearded man in a white sweatshirt littered with Clinton/Gore campaign buttons. This super-supporter is Tim Wilkins, a Toronto social worker originally from Florida. When asked what policies attracted him to support the Democrats, Wilkins becomes flustered and unable to give any specifics.

“Been with the Democrats since 1988,” says Wilkins. “I could not identify with the Republicans at all. I think Bush was a very poor selection, and when he selected Dan Quale as his running mate, I thought ‘my Lord, you’ve just blown that ticket.’ The Republicans are just too right-wing, completely out of touch with Americans. And that’s an example of what’s happening tonight. Bob Dole and (running mate) Jack Kemp are completely out of touch. They have no agenda, no economic plan.”

Clinton and Chretien

Byron Toben, a Montreal Democrat, thinks a Clinton win will cement the close personal relationship between Clinton and prime minister Jean Chretien.

“Clinton and Chretien have something of a mutual admiration society going,” says Toben, who does immigration work, helping US citizens to move to Canada. “Clinton and Chretien are both on the same wavelength.”

Anne Kerr, the Canadian-born wife of Tom Ward, also agrees. She says Clinton’s victory is important to Canada because Liberals have more in common with the Democrats than the Republicans.

True enough, both Chretien and Clinton represent parties traditionally viewed as left-of-centre. Both men ran on vaguely liberal platforms for election, and both turned sharply conservative after deciding that deficit-reduction was more important than social spending or government activism. The federal Liberals in Canada and the Democrats in the United States now support conservative agendas that aren’t too much different than the platforms of their right-wing rivals. The biggest difference between the two nations, as Ward points out, is that the United States now lacks any major left-wing party such as the New Democrats. The Greens, running as a left-wing alternative to the Democrats, with consumer crusader Ralph Nader as their candidate, pulled in slightly more than a half-million votes on November 5. That is more than other minor parties such as the Libertarians or US Taxpayers Party, but hardly enough to convince Clinton to turn sharply leftwards in his second term.

Disappointment with Clinton’s first term aside, the Democrats Abroad party briefly jolts awake towards the end of the evening when Clinton’s re-election is confirmed. Champagne corks are popped by the club’s wait staff, but nobody is in a hurry to grab a glass. The mood becomes slightly effervescent as tipsy Democrats grow more animated, only to be hit with some mind-numbing post-victory speeches by the group’s executive. After a few toasts, the moment passes and a steady stream of Democrats slips out, thankful their man had won over Bob Dole, becoming the first Democratic president to win a second consecutive term in office since Franklin Roosevelt in 1936.

Id Magazine was published in Guelph, Canada in the 1990s.

Books by Nate Hendley: 

Al Capone: Chicago's King of Crime, Five Rivers Chapmanry, 2010

American Gangsters, Then and Now: An Encyclopedia, ABC-CLIO, 23 Dec. 2009 

The Big Con: Great Hoaxes, Frauds, Grifts, and Swindles in American History, ABC-CLIO, 2016

Black Donnellys: The Outrageous tale of Canada's deadiest feud, James Lorimer & Company, 2018

Bonnie and Clyde: A Biography, Greenwood Publishing Group, 2007

The Boy on the Bicycle: A Case of Wrongful Conviction in Toronto, Five Rivers Publishing, 2018

Crystal Death: North America's Most Dangerous Drug, Five Rivers Chapmanry, 2011

Dutch Schultz: The Brazen Beer Baron of New York, Five Rivers Chapmanry, 2011

Edwin Alonzo Boyd: Life and Crimes of Canada's Master Bank Robber, James Lorimer & Company, 2013

Motivate to Create: A Guide for Writers, Five Rivers Chapmanry, 2010

Publications by David South: 

Southern Innovator Magazine Issue 1: Mobile Phones and Information Technology 

Southern Innovator Magazine Issue 2: Youth and Entrepreneurship

Southern Innovator Magazine Issue 3: Agribusiness and Food Security

Southern Innovator Magazine Issue 4: Cities and Urbanization

Southern Innovator Magazine Issue 5: Waste and Recycling 

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Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.

 

Man out of Time: The world once turned on the ideas of this Guelph grad, but does the economist John Kenneth Galbraith know the way forward?

By David South

Id Magazine (Canada), January 23 to February 5, 1997

It was with hungry enthusiasm that I rushed to hear the great liberal economist John Kenneth Galbraith speak. It was with enormous disappointment that I found a genius emptied of solutions to the current political battles in today’s Ontario.

For those unfamiliar with Galbraith, think of him as a hybrid of the liberalism of former prime minister Pierre Trudeau and the manner of Jimmy Stewart. Now 88, the former Guelph agricultural economist became a servant of the US government just as president Franklin Roosevelt was beginning to introduce the New Deal – today’s rusting welfare state – as a solution to the cruel hardships imposed on Americans as a result of the Great Depression. Galbraith rode out the Second World War in a senior government position as Roosevelt’s price-control czar. He later advised Democratic presidents John F. Kennedy and Lyndon Johnson, before seeing his influence in American economic thought wane under Ronald Reagan’s Republicans.

Galbraith has long followed the ideas of British economist John Maynard Keynes, who believed goverments should keep money tight in good times, but should spend their way out of bad times to avoid undue hardship. Galbraith also made the plight of the poor one of the pillars of his economic theory, and criticized the unnecessary appetites and demands created by the goliath American advertizing industry. He has supported wage and price controls and once, in the 1930s, even wanted to join the American Communist Party.

Last week, Galbraith breezed into Toronto with his ivy league roadshow. Speaking to a stodgy crowd of liberals (and Liberals, including former prime minister Pierre Trudeau and failed Ontario leadership candidate Gerrard Kennedy) at the University of Toronto, Galbraith was at an institution that comes as close as Canada gets to his current stomping ground, Harvard.

Symbolically, Galbraith couldn’t have visited Ontario at a better time. The Conservative government of Mike Harris is in the middle of an ambitious campaign to reverse everything that Galbraith has stood for: budget deficits to avoid depressions; social programmes to prevent poverty; taxes on the rich to fund those programmes; government policy subservient to public good. Harris oozes contempt out of every pore for the pillars of Galbraith’s thinking. In fact Ontario, once the bedrock of Canadian liberalism, is now joining Alberta in dismantling the welfare state.

A graduate of the University of Guelph when it was still the Ontario Agricultural School, Galbraith took his bitter memories of farming in southern Ontario to the University of California, Berkeley and subsequently to the Roosevelt government.

In his day, Galbraith was amongst a rare species of mainstream economists that earned respect from the once-abundant Marxists who cluttered universities. Not that the Marxists liked his compromises and complicity with the American government, or his assertions that he could save capitalism. But they thought he softened up the system for some body blows to be delivered by the workers’ revolution.

I am a member of generation that grew up on government largesse, well-funded public schools, family allowance, university grants, and make-work progammes. But we have seen a lot of that eroded over the past eight years, during a period of high unemployment not seen since the Depression. It was time to see if this titan of liberal thought had something new to say.

Galbraith’s talk had two main points: the market economy is the best system going; he supports a guaranted minimum salary to prevent poverty. Other than that, Galbraith’s speech was a rehash of the same ideas he has been mulling over for the past 50-plus years. It could be called Liberalism 101.

His speech was peppered with euphamisms like the “socially concerned.” Perhaps he was pulling his punches so as not to offend the “distinguished” audience. The most exciting moments displayed his dry wit: “In the United States , the war against the poor having now been won,” or “We, the socially concerned, do not seek the euthanasia of the rentier class.”

He struck out against annual balanced budgets because they have been used as an excuse in the US to cut off benefits to the poor. He also slammed the globalization-uber-alles philosophy that sees welfare policies as uncompetitive – a sentiment that doesn’t seem to be in vogue these days with liberals. Last week, Prime Minister Jean Chretien told the South Koreans they need to remove jobs-for-life provisions to join the global marketplace.

His ideas and his approach to communicating those ideas come from a special historical time. A time when governments under pressure from trade unions and the far-left and right political parties decided to make capitalism a little friendlier. But they needed advisers who could speak the language of the elite. Eloquent, confident, pragmatic – advisers who felt comfortable in the courts of the democratic government. They didn’t want hot-headed union guys or hectoring left-wing demagogues.

Galbraith takes credit for civilizing capitalism and ensuring its survival: “It would not have survived had it not been for our successful civilizing efforts. We, the socially concerned, are the custodians of the political tradition and action that saved classical capitalism from itself. We are frequently told to give credit where credit is due. Let us accept it when it is ours.”

Galbriath’s economic theories have always been grounded by morality, preferring to avoid being a servant to flow charts. It is his most insightful side. When many fear to speak in broad terms about current economic problems, where many fear to make connections, Galbraith has pieced the complex puzzle together, much to the frustration of those who believe capitalism should be left unfettered. It is his worthiest legacy.

The Galbraith Interview

You point out it is reforms that have given capitalism a new lease on life. What policies would alleviate the worst aspects of today’s capitalism?

We still have the oldest problem. (That is) to eliminate the cruelties that are inherent in the system. In the United States, and I imagine also in Canada, we still have the terrible problems of the urban poor, of the people who do not make it. I see one of the central tasks of our time is to do two things: to provide a safety net so that in a modern rich society we don’t let people starve, and that we provide the means for escape from urban poverty.

How would you elliminate poverty?

No novelty about that. Two things are absolutely essential. One, that there be a basic safety net. That we accept in a modern society that there has to be a level of income below which people are not allowed to go. I do not join this attack on welfare, this notion the poor should be allowed to starve. Another thing is a strong educational system, which allows people to escape from poverty in the next generation. Those are the two absolute essentials.

Should government just concentrate on ending poverty and abandon universal programmes like public health care?

You can always have a conversation that separates itself from the reality. I think in Canada if some politician or some political group wanted to repeal the health system, they would soon find themselves in considerable disfavour. If they were committed to allowing the poor to starve, they would get a reputation for cruelty that no civilized society would tolerate. And if they started saving money on the schools, as some already have, we would find out how absolutely essential good education is for economic and social well-being. So we have a difference between what is possible in oratory and what is possible in reality … When the axing comes, it is a good deal less popular than it is in the previous rhetoric.

Who do you think, within or outside political movements, represents the socially concerned today?

I don’t speak generally on this. There is in all countries a substantial voting and politically expressive group. In the United States it is the political left, in Britain it is the Labour Party, in France it is the socialists, in Germany the social democrats. They are broadly committed to the welfare state and I think will remain so.

Would you include the Liberal Party in Canada amongst those?

I would include a substantial part of the Liberal Party in the United States. The Liberal Party in Canada, like the Democrats in the United States, have a double orientation, on one hand to the welfare state and on the other hand a more centrist attitude. Both parties have an internal problem to resolve.

Do you think they have lost interest in the welfare state?

To some extent I regret that. We must take some responsibility for human suffering and human well-being.

You don’t see that with the Democrat Party?

I prefer it to the Republicans.

Are some of these policies like welfare reform in the US making it harder for the poor?

I was not in favour of welfare reform.

I grew up in a very poor household but was able to go to the University of Toronto because of various government policies. In fact, they have kept me from destitution. You have written about a culture of contentment that prevents further social reforms. Will it whither?

Those of us who have been associated with the welfare state have made a lot of people comfortable, happy and conservative. We have undermined our own political influence by our success.

Do you think current levels of high unemployment and economic stagnation might erode that contentment?

No, if we suffer another recession there will be a desperate effort to have the government do something about it. The present conservatism is an aspect of good times. We had it in the 1980s under Reagan.

Are we still in good times?

We still have a lot of people who have a problem. We should have sympathy.

Do you see any political parties in Canada who defend the welfare state?

I’ve lived all my life in the the United States and I’ve always avoided coming back to give Canada advice. As I said in my lecture, anybody who does that should have stayed in Canada for his own lifetime. Let Canadians look after their affairs in Canada.

You said the socially concerned don’t seek income equality. I guess that is where you split with socialists?

I accept the inevitable, that people are going to be different in aspirations, ability and luck and probably different in parentage. All of this is going to mean differences in income.

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Taking Medicine to the People: Four Innovators in Community Health

Preventing and treating illness at home or in small local clinics makes financial sense. It also makes patients a whole lot happier.

By David South

Canadian Living (Canada), January 1993

Your health is your wealth, my grandmother used to say. It certainly is our most valuable resource – and when its caretaker, universal health care, is under attack, people take notice

Provincial health ministries across Canada are scrambling to find new cost-efficient ways to deliver health care, and community health care is an increasingly talked-about option.

“Every royal commission has suggested we need to shift resources to community care and stop focusing on institutions,” says Carol Kushner, co-author, with Dr. Michael Rachlis, of Second Opinion (HarperCollins, 1990), a blockbuster book that challenges the way we approach health care in Canada. According to Rachlis, health care nationally cost more than $60 billion in 1992 and is primarily delivered through hospitals and doctors’ private practices. Yet 20 per cent of all patients in acute care hospitals don’t belong there, and about five per cent of hospital admissions for people over age 65 are the result of improper use of prescription drugs.

One study of the Toronto Health Unit found that as many as 50 per cent of seniors residing in nursing homes who were admitted to hospitals with pneumonia had contracted it through mouth infections. If they had received regular dental check-ups in the community or at institutions, these unnecessary and costly admissions could have been avoided.

Increasing numbers of people see community health care as the way of the future. In this model, health care providers – doctors, nurses and support staff – work as a team, and users of health care are involved in making important decisions. Community-based care supplements a medical approach to illness, with emphasis on social and environmental factors like work-related stress. Its advocates say community care can wean us off our addication to expensive hospitals (where one bed costs at least $100,000 a year), drugs and surgery – and make us all healthier.

“Fee for service” encourages doctors to see as many people as possible, emphasizing quantity over quality. In community health centres, doctors are put on a salary and encouraged to give as much attention as necessary to each patient. By simply spending more time with each patient, and by taking into account factors such as illiteracy and cultural differences, community clinics can cut down on misuse of medication.

Jane Underwood, director of public health nursing for the regional municipality of Hamilton-Wentworth in Ontario, says we have reached the limit of what hospitals can do to improve health. “Other factors are now more important than a strictly medical approach, which was the foundation of the old health care system. In 1974, a Health and Welfare paper urged a behavioral approach – stop smoking, get more exercise. Now we are moving to a socio-environmental approach, looking at poverty, social isolation, and unemployment, and their effects on health.”

“Community health care is inevitable because we can now do many procedures on an outpatient basis. With the new technology, all kinds of things can be done outside institutions,” says University of Toronto professor Raisa Deber, co-editor of the recently released book Restructuring Canada’s Health Services System (University of Toronto Press, 1992).

“Just as people can work out of their homes because of computers and faxes, technology can take medical care to the home.” This trend can already be seen in the treatment of cancer. Many patients now receive their chemotherapy at home, with the help of computerized IV pumps.”

If the debate over community health care often seems confusing, it may be because of the haphazard patchwork of programs across Canada. Quebec is the only province that took community health care seriously enough to set up clinics across the province in the 1970s and make those clinics an integral part of the provincial system. Elsewhere in Canada, programs sprang up in the ’60s and ’70s at the initiative of community activists but were met with indifference or hostility from government.

The challenge for community care advocates is to educate both the public and governments. Jane Underwood admits it will be a tough struggle. “Governments are beginning to understand, but the public still has reservations. They panic when there are fewer surgeries and feel that lots of high tech will provide a safety net for health. In fact, it is more scientific to probe for the true causes of illness and not think that just taking a pill will make us better.”

Four Innovators in Community Health

South Riverdale Community Health Centre, Toronto

This fully functioning health centre opened in 1976 in Riverdale, a multicultural and economically diverse neighborhood. The staff consists of doctors, nurses, chiropodists, social workers, health promoters and a nutritionist. Innovative in taking on economic concerns of the community, the centre has set up a community food market to provide cheap and healthful food and recently started workshops with business and community members to come up with strategies to recover jobs lost during the recession. "We consider ourselves part of a movement," says executive director Liz Feltes. And this is played out in projects with local groups and citizens on a variety of issues - from wife assault, drug abuse and sexually transmitted diseases, to medication literacy for seniors. 

Victoria Health Project, Victoria

Originally started in 1988 to tackle the problem of poor communication between hospitals and community health providers, the project first targeted Victoria's large senior citizen population. Twelve programs were launched, including Wellness Centres, palliative support teams for patients dying at home and elderly outreach service focused on mental health. The project has been successful at getting local services to cooperate and eliminate duplication. "There are 500 different agencies for seniors in Victoria, so we linked up with them and increased cooperation," says Susan Lles, excutive coordinator of the project.

It was such a great success that the minister of health created the Capital Health Council to expand the program to the rest of the community. Now, for example, in hospital emergency rooms, quick response teams of nurses assess whether a patient would be better served by other services in the community or by being admitted to hospital. 

Centres locaux de services communautaires (CLSC), across Quebec

Started in 1972 as part of province-wide health reforms, these comprehensive health centres now number 158, with more than 500 satellite offices all over Quebec. Every citizen is guaranteed access to a CLSC, even in remote areas. With five per cent of the provincial health budget, they are able to serve 41 pr cent of the population. They also involve the community through elected boards. "We think it is a unique model in that it integrates health and social services in the same place - both prevention and cure," says Maurice Payette, president of the federation of CLSCs. Because CLSCs are close to the community, governments, schools, community groups and other organizations have turned to them for advice during the last five years. In rural areas, CLSCs have been crucial in reducing the number of farm accidents. 

Canadian Healthy Communities Project (CHCP), across Canada

Started in 1989, the program is aimed at municipalities and gets them to pledge that they will review all their actions with community health (including impact on the environment and economy) in mind. CHCP is part of an international movement linked with the World Health Organization's Healthy Cities movement. With more than 150 participating programs, it is an innovative attempt at getting the powers that be to plan for overall health. "We bring together community leaders to make a list of top 10 health problems and then decide what can be done with the existing budgets and staffing," says David Sherwood, project director. The city of Sherbrooke, Que., is a classic example. Facing reduced funds for road and sidewalk repairs, the city concentrated on repairs in neighborhoods with hig numbers of the disabled and elderly, thereby reducing the number of accidents. Unfortunately, funding was recently reduced dramatically by Health and Welfare Canada, but programs in Ontario, British Columbia and Quebec continue with the help of their own provincial government. 

"Taking Medicine to the People" was published by Canadian Living in 1993.

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Take two big doses of humanity and call me in the morning

By David South

The Toronto Star (Toronto, Canada), January 1, 1993

“Anybody going into medicine should read a whole bunch of good novels.” Dr. Alvin Newman isn’t kidding. The head of curriculum renewal at the largest English-speaking medical school in the world, the University of Toronto, feels strongly that doctors have been ill-prepared for their profession’s challenges.

How doctors become doctors is being hotly debated as Ontario’s five medical schools institute a potpourri of curriculum reforms. After a century of taking a back seat to scientific achievement, bedside manners and the art of medicine are in vogue again.

“Around the world, medical education is undergoing significant changes,” says Newman. “Medical schools must strike a balance between the incredible explosion of scientific knowledge and re-establish the role of the physician as wise counsel and empathic healer.”

It’s a role that many feel doctors have ignored. An American Medical Association poll, conducted between 1985 and 1988, found that fewer than 50 per cent of respondents said they thought doctors listened well and half believed doctors no longer care as much about patients as they used to.

In response to these criticisms, current reforms are shifting medical education away from reliance on the turn-of-the-century science-based approach, says Professor Jackie Duffin, a medical historian at Queen’s University who helped organize the new curriculum introduced there in 1991.

“In the old days doctors could probably make a diagnosis and tell people what was happening to them, but not do very much for them,” says Newman.

“Yet society had more trust and fondness for physicians than they do now. Much of the condemnation of the medical profession is because we have become the custodians of high-tech medicine.”

While the Ontario government embarks on the most sweeping reforms to health care since the 1966 introduction of comprehensive health insurance in Ontario and the founding of national medicare in 1968, many doctors feel their profession cannot afford to maintain the status quo.

The concensus at Ontario’s five medical schools – U of T, Queen’s, University of Western Ontario, University of Ottawa and McMaster University – has gelled around a belief that doctors need to be as comfortable dealing with people as they are with scientific medicine. To this end, revamped curricula supplement basic science and clinical medicine with emphasis on early exposure to patients, communication skills, psychological issues, medical ethics, medical literacy and health promotion.

These schools hope to produce new doctors to fit into a rapidly-changing health care system – one that many believe will rely far less on large hospitals.

Instead, many procedures will take place in the home or in the day clinics. Expanding community health care care centres will try to tackle extensive social and health problems. This preventive approach ot medical education was pioneered by Hamilton’s McMaster medical school.

Since its founding in 1967, McMaster has experimented with teaching methods that steer away from mass lectures to concentrate on the individual student. The evolution of McMaster’s curriculum has placed greater emphasis on communication skills, psychosocial aspects of medicine, community issues, and disease prevention and health promotion.

How do McMaster students rate against other medical students?

Last year they scored above the national average on licencing exams. A higher proportion of McMaster students enter research and academic medicine than their counterparts from other schools. One study comparing them to U of T suggested they were more motivated to be life-long learners.

Dr. Rosanna Pellizzari practices the kind of medicine everyone is talking about these days. Working out of renovated church, Pellizzari’s practice at the Davenport/Perth Community Health Centre in westend Toronto serves a working class neighbourhood that has been home to generations of recent immigrants.

A member of the Medical Reform Group – which has long advocated significant reforms to health care – and trained at McMaster, Pellizzari can be seen to represent the doctor of the future: Sensitive, salaried and working in community health.

“McMaster’s curriculum attracts people with innovative ideas,” says Pellizzari, who was active in community health education before going to medical school. “It is a very supportive environment.

“I think the important question is: Who do we choose to be medical students? They should open up medical schools to those who know what it’s like to be a parent, a mother or disabled. Doctors should represent the population they serve. We are still getting mostly white, inexperienced young males as physicians. They aren’t going to practice the way that is necessary.”

In Ontario, many doctors see the 1986 doctors’ strike as a watershed for public opinion.

As a result of the negative fallout from the strike and perceived gap between physicians andhe public they serve, a five-year project entitled Educating Future Physicians for Ontario became a major advocate for reform.

Started in 1988, EFPO has examined fundamental issues in designing and implementing new medical school curricula. These issues include defining societal health care needs and expectations, faculty development and student evaluation. While each medical school has adapted reforms to its particular situation, EFPO hopes to prod further reforms.

“This is a unique venture in Canada, and could have implications far beyond Ontario if successful,” says Dr. William Seidelman, a key player in EFPO. “It captures the unique sense of the Canadian scene, and will build on the implied contact in the Canadian health system.”

Pellizzari sees the attitude of medical schools and teaching hospitals towards medical students as a significant factor in creating insensitive doctors. She recalls the high rate of suicide among medical students and the abusive work environment that forces doctors-in-training to work shifts unthinkable for other workers.

“The way we train doctors is inhumane,” she says. “We don’t expect other workers to put in 30-hour shifts. It creates in new physicians the attitude that they paid their dues and now society owes them.”

Many critics feel that changing training methods isn’t enough; the whole ethos and selection process must be changed. If doctors are to better serve the population, they must better reflect it.

“We are getting very close to gender equality and a laudable distribution of ethnic and racial backgrounds,” says Newman. “But students still come from a fairly narrow social spectrum,  very middle class kids. Their exposure to the extremes of society, to poverty, to homelessness and related illnesses have been very limited.”

Pellizzari found how out-of-date the medical profession was in her first year. One teacher wanted her to work till 10 at night. When told that she needed 24 hours notice for a babysitter, the teacher shot back that motherhood and medicine don’t mix.

“I was a mother before I was a physician. When I get a call at night from a mother, I understand this. With 30 per cent of visits to doctors having no biological basis – like depression due to unemployment – you can’t do anything unless you have experienced life.

“If we don’t address this, you can design the best training in the world, but things won’t change.”

But Newman also feels many factors outside of medical school discourage a more diverse student body.

“To go through medical school in the United States requires large indebtedness. That’s not true in Canada. You can calculate what a year of medical school costs in terms of a finite number of CDs, a leather jacket and ghetto blaster. So something is dissuading people from pursuing this career, and it isn’t money.”

While there is a concensus among academics that medical schools haven’t prepared doctors well enough, there is little support for a dramatic change in selection criteria. “I can’t muster a lot of support from colleagues for serious changes,” says Newman.

Dr. Jock Murray, the former dean of Dalhousie medical school in Halifax, recently told an EFPO meeting he doesn’t see any significant changes ahead.

“Physicians have a reputation for being conservative and self-serving,” says Murray. “If reform is going to be successful we have to be clear that it is about what is good for the people.”

Pellizzari believes life experience and empathy with social circumstances just can’t be taught.

“I grew up in this neighbourhood. I understand their powerlessness, the conditions. Doctors have to see themselves as a member of a team of health professionals, not as the top of the social and medical totem pole.”

U of T’s experience is a classic example of the hurdles ahead. Newman admits it has come as a shock to students loaded with society’s ingrained expectations.

“They spend half a day a week in the community seing things like drug rehab clinics and community health centres. But being out in the community doesn’t make the students feel comfortable. Their image of what they are going to do involves big buildings, chrome and steel, scurrying personnel and banks of computers.”

'Take two big doses of humanity and call me in the morning' was published in the Toronto Star in 1993.

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