Healthcare Quarterly
Abstract
Dr. MacDonald was named Dean, Faculty of Medicine, Dalhousie University, in July 1999, the first woman to become a dean of medicine in Canada. She concurrently holds university appointments as Professor in Paediatrics, and Microbiology and Immunology, and is cross-appointed at IWK Health Centre as Professor of Paediatrics and Microbiology. Even with her heavy academic administrative responsibilities, she continues her paediatric infectious disease clinical service.
Dr. MacDonald has long been recognized nationally as an advocate for children and a leader in paediatric infectious disease, with major research interests in the microbiology of cystic fibrosis, stress management in medical faculty, sexually transmitted diseases in adolescents and vaccine development for infectious diseases in children. She has published more than 170 papers, been on the editorial board of several major publications and is founding editor of Paediatrics & Child Health, a journal of the Canadian Paediatric Society. Dr. MacDonald has been an active participant in many national and international societies and organizations as well as federal government committees. She has received numerous awards and honours, including the Canadian Infectious Disease Society Distinguished Service Award, the University of Ottawa Award of Excellence and a visiting scholarship to the University of Oxford Institute of Molecular Medicine.
What's with all the health reports now? Besides funding
pressures, why is there such a drive - competition almost - to
alter health systems?
I think health has finally made it onto the national agenda in a
big way, pushed from the U.S. with the Clinton initiative and an
organized media campaign. Here, as times got tight, provincial
governments looked into budgets, and health was their major cost.
People are also fed up at the bickering among federal and
provincial politicians. Romanow's commission was put into place
because the issues required a comprehensive review, and it's all
part of the feeding frenzy in pushing the issue forward. When
medicare came in, it was very paternalistic and hierarchical.
What's changing is recognition that healthcare has to be based on
partnerships. Good health requires families, communities,
governments, healthcare and businesses all to work together. That's
a different thought process from that in the '60s. The Dalhousie
Research Foundation conducted our own health forum last June, in
advance of all the reports, and brought together an eclectic mix of
people. It's heartening to see that much of what's coming out now
is in our report (www.dmrf.org - click 2001 Fall River Forum).
What do you think of fee-for-service and alternative payment
mechanisms?
Fee-for-service grew out of the hierarchical paternalistic system
and is a huge problem as it was based on procedures, not on disease
prevention or management. Alternative fee payment (AFP) systems
represent recognition that fee-for-service doesn't fit all
healthcare delivery anymore, with one reason being that if you're
an expert, you don't get paid for a telephone consultation with
another physician - you only get paid for seeing patients. Some
high-paid procedures that in the 1960s were very high risk, you can
now do in 15 minutes, but the fee didn't go down. There is a
problem with balance here.
Sure, cataracts in Ontario average $800 for a consultation,
surgery or a follow-up, and six out of 10 physicians in Ontario who
billed more than $1 million in 1999/2000 were ophthalmologists.
Isn't something wrong?
Yes, that's the example I was thinking of. There's work within the
system to realign, but it's difficult to take away something from
someone that they've always had. With Alberta's recent statement to
the effect that 50% of physicians would be in AFPs, I think change
is quite realistic. We have to look at the deliverables and
outcomes that physicians are being paid for, and physicians with
the AFPs have to be accountable, whether it's for teaching medical
students, doing research, delivering clinical services or
developing policy.
Do you think tenure is still appropriate for publicly funded
universities?
I think the issue comes back to accountability in public
institutions. The same thing is happening in healthcare, and I
don't think universities are immune. Tenure came in when freedom of
speech was a big issue and we didn't have a lot of accountability
from outside, but the public is growing increasingly concerned that
publicly funded institutions provide good value, whether that's
hospitals, elementary schools or universities. There are concerns
about quality of education. Similarly, the public is holding
medical licensing bodies accountable, in that if a physician is
providing poor care, there's sexual impropriety,or communications
issues, his or her licence may be pulled. The public expects this
now and the medical profession cannot turn a blind eye to
misbehaviour anymore. I think university teachers and researchers
need to be allowed freedom of speech and research in
non-politically correct areas, but tenure should have public
accountability for quality and quantity of academic output.
A great strength here is the inclusion of the humanities,
such as the art in medicine show and Dalhousie Medical School
Chorale, unique among universities. How do the humanities help
students be better doctors?
It helps with stress, with perspective and allows them to be more
than a pair of hands and a brain. The art show came from the
students themselves and the past three years focused on
transplantation, Alzheimer's and Attention Deficit. It's
recognition from early on in medical education and encouragement by
the faculty that future physicians will be recognized and valued as
whole people. It's entirely possible to become so sucked into
medicine that you lose perspective on what it's like in the "real
world." The humanities ground us in recognizing there's more going
on in the world. This is linked to healthcare in a partnership
model, because if you understand what to do to improve health, you
need to ensure that your personal health is also being dealt with;
your spiritual, social and emotional health. Students also see
faculty participating and feel positive community response to what
they're doing.
Is there a particular management theory you find
valuable?
Disruptive innovation, out of Harvard University. I feel I've been
a disruptive innovator my whole life and I never knew that's what I
was doing! Essentially, you look at a segment of the market that's
at a very low level, that nobody's paying attention to, and you
provide just what that market segment needs and do it better than
anyone else. An example where disruptive innovation might work in
healthcare is caregivers for street people. We currently have no
one trained to deal with all the problems. We should train one
worker who has "street" expertise - some each of social work, foot
care, mental health, addictions and just how to fill out forms. The
system is so complex we're trying to pay attention to everything,
but because of hierarchy, we have professional relations and silos,
which make it difficult to address patient group needs. Instead of
asking what the system needs, let's ask what a patient group needs;
what are the geography and resource issues. Not the other way
round, which is to build the system. Let's find a little hole where
a patient can come in.
You've spoken with Roy Romanow. What are some issues you hope
the commission addresses?
We need public education that helps people understand what the
health system buys and what it doesn't, and what are the
implications. Gut-wrenching stories about an individual sway the
public, while other health stories are not so newsworthy; for
example, vaccines are not sexy. We need balance in anecdotal
reports, as almost always we have to justify that vaccines will
save money. We don't have these conversations in other areas, for
example, P24Ag testing on blood still distresses me. This test for
HIV decreases the window period, but by only a few days. In the
United States, every case of HIV from infected blood transfusions
prevented through P24 antigen testing is estimated to cost
$880,000US. Since P24Ag testing on blood in Canada started during
the Krever Commission, we've not prevented or picked up one case by
this intervention. When I tell any audience this, 90% of people are
appalled that millions have been spent on this with little or no
benefit, but 10% say it's right to make the blood system as safe as
possible. P24Ag testing is not the problem; it's what we are not
doing to pay for this and how healthcare spending items are
prioritized.
Another issue is the age difference in medicine. For medical students, residents, and those in practice largely under the age of 45, the vast majority will talk to you about quality of life in practice, staying current and how difficult that is with the ongoing avalanche of technology and information, and of the need to work in teams and groups, because they want peer support to deliver 24/7 care. In physicians over 50, they speak very much about autonomy and don't want any controls; they say, "Just pay us more and we'll do it." James Clarke, president of the Canadian Association of Interns and Residents, who's at Dalhousie training in radiology, said a very important thing. This generation is the new face of medicine - they're physicians of the future. So some of what other older physicians are saying may not jive, because they're of another generation. New physicians need to be part of any discussions on reshaping the system.
Is that different from U.S. medical students? An article in
Academic Medicine recently stated that medical schools teach
students the doctor/patient relationship is a business that
undermines teaching and care.
The American system is a business in many HMOs. When I was visiting
professor for the Paediatric Infectious Disease Society at the
University of Michigan Medical School for five days in the
mid-1990s, each doctor asked me specifically about the Canadian
system. I'm no healthcare economist and I wanted to talk about
infectious disease! But Americans are fascinated with our system,
especially as theirs is under increasing stress. It's a big issue
for me that medical students are not taught enough about how health
systems work. We're working on correcting this at Dalhousie, but
many MDs in practice still see themselves as individual
entrepreneurs outside "the system."
One role is to obtain funding for research and clinical
programs - is this difficult?
Very. Dalhousie and three other medical schools in Canada have
small populations with relatively large geography, so problems in
funding infrastructure, recruitment and retention are naturally
more difficult. It's hard to sustain quality research without
significant external funding. For example, at Dalhousie we've had
no new space built for medical research in more than 30 years. This
is very important to healthcare in the region, since there's a
major intertwining of health research and clinical care. Think of a
tricycle with education and research as back wheels and clinical
care at the front, driving towards improved health. If a back wheel
falls off, it's pretty hard to drive. Research is also a big-ticket
item in the local economy - here we bring in more than $35 million
a year. I could be saying the same thing if I was at Memorial,
Saskatchewan or Manitoba, because in all of these have-not economic
regions, the medical faculties have difficulty in sustaining access
to quality clinical care and maintaining a vibrant research and
educational community. If the medical schools were not in place,
much tertiary care would leave these regions. So, going back to
Romanow, sustaining faculties of medicine and academic health
science centres in regions with dispersed geography and economic
problems must be considered federally if we're going to have equity
of access in Canada.
What are your assets?
Many have told me that I'm energetic and quick. I think I'm a very
good connector and think out of the box. I'm an optimist - tell me
what the problem is and I'll work towards solutions. I'm also
passionate about the work I do, but with people who are concrete,
narrow, and sequential thinkers, I need to be more patient. One
thing that's a difference - maybe this is a woman thing - I've
never been a power person. Some men I've worked with have been far
more interested in power; to get honoured or get credit than in
finding solutions to problems. I couldn't care less - I want the
solution. I think I frustrate some people, as they don't understand
the currency I trade in and how I measure success - it's different
achieving the goal, hopefully by consensus, and following through
is what counts.
You're the first female dean of medicine in Canada; surely
you faced difficulties.
When I was on the short list here, I specifically asked if I was
the token woman. If so, I didn't want the job - I don't do token
woman. While there are still a few dinosaurs, in the generation
that's coming up things are changing. I grew up when women in
senior academic medicine were not the norm, and I learned to
survive. I was extremely fortunate to work with a couple of
forward-thinking department heads who were ahead of their time to
be so enlightened. When I initially started on faculty in Ottawa,
at far reduced wages than males doing the same job, my department
head set about fixing it. That was in 1982. Within three years, my
salary doubled because I'd been started out for less than my
counterpart males; I was naive and I didn't know what men were
paid. Fortunately, times are changing, and many more women are in
academic medicine and some are moving up.
What do you do for fun?
I ski, travel with my husband and kids, and read books. In Ottawa,
I took pottery classes, but I haven't here, as I've been so busy. I
enjoy pottery because I get to use a piece of me that isn't valued
in my other world, and this goes back to the importance of the
humanities in medical education. Working with clay is restorative,
whereas with bad diseases, some patients died despite the best care
we knew how to give. While one can really make a difference in
making death as gentle and as caring as possible, it takes a lot
out of you. In contrast, in pottery, no one dies. If one of my
pieces doesn't work out, who cares? We all need a place in our
lives where decision-making isn't so critical and success is
measured on a more personal, different scale.
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