Insights (Essays)

Insights (Essays) January 2017
Open Letters

Dear Class of 2020

Dr. Danielle Martin

This letter is part of series of Open Letters from Canadian leaders in Healthcare. To see the complete series please click here 


Dear Class of 2020,

When I finished my interview for medical school, I cried. I was sure that I might never be given a chance to be a doctor.  Many of you were probably as surprised when you got your acceptance letter as I was when I got mine, and in these early months in medical school of trying to learn the branches of the brachial plexus, you will at times wonder if the committee made a mistake, or if perhaps you did.

But as you hit the wards and experience all those unforgettable firsts – the first time you hold a scalpel to cut through human tissue, the first baby’s head you support as it enters the world, the first patient you have to apologize to – you will know that you are where you belong. You will have the immense privilege of knowing that most days, you do work that helps people. You will be well-paid, earning at least three to four times the money your average patient makes. People at dinner parties will treat you with respect. Your future, which is inextricably linked to the future of the Canadian healthcare system, is bright.

And yet, as you look around you, even now and certainly in the years to come, you may notice something about the guild you have chosen. Along with nurses, rehab professionals, mental health professionals, and so many others, doctors roll up their sleeves every day to take care of people who need our services. But unlike those other groups, doctors often see themselves as separate from the healthcare system we work in. This matters now, more than ever, because our healthcare system needs us.

The future of healthcare is defined not by a linear trajectory of “progress,” but by a series of competing tensions that our decision-makers will need to navigate. These tensions can only be resolved at the system level, and with your participation. Among these tensions, three stand out for me:  1) the tension between population health and personalized medicine; 2) the conflict between high technology and the rise of “slow medicine”; and 3) the friction between standardization and individualization of care.

The tension between population health and personalized medicine is already at play. On the one hand, high-performing health systems are increasingly focused on the health of populations, not individuals. You will be asked to think of your practice population as the unit of analysis in more and more of your work. Decisions about what care is publicly funded and which guidelines shape clinical practice will be based on population health approaches. Yet simultaneously, increasing numbers of personalized medical solutions will emerge as researchers learn how to tailor therapies to the genetic needs of the individual.

The conflict between the rise of high technology and the resurgence of slow medicine will challenge you. Advances in technology will bring our diagnostic and therapeutic powers to new heights; yet at the same time we will increasingly learn about the harms our tests and interventions do to patients. Calls to “choose wisely” will echo in your ears even as you reach for the pen to fill out requisitions for the use of ever-more powerful tools.

Prepare for the friction between standardization and individualization of care. Our current treatment approaches lead to unacceptable variations in patient outcomes across the country; as quality improvement initiatives proliferate we will increasingly be held to common standards, checklists, and clinical practice tools. Yet at the same time our patients will demand that we see them as holistic and complex individuals, each needing a unique kind of interaction and intervention to facilitate wellness and healing.

These tensions won’t be resolved because one force emerges victorious over the other. Rather, the future will be defined by a constant – hopefully productive – tug-of-war requiring moment-to-moment negotiation. You will need to participate in building systems that can respond to that kind of complexity, or we will tip the system away from the balance needed to successfully harmonize these competing tensions.

In training, you will rightly learn over and over that the individual doctor–patient relationship is a sacred one. But do not forget, that relationship exists in a complex web. It’s too easy to interpret that “the system” is something from which patients must be protected rather than the very infrastructure that allows us to care for them in the first place.

This points to the tension that, in some ways, underpins them all, which is the tension between social accountability and self-interest. As doctors, we are well-paid and hopefully well-respected, and those things are nice, but not enough. They should be secondary to the primary purpose of our profession: meeting the health needs of the communities we serve. This concept of service is often invoked to urge us to practice in more altruistic ways, in rural underserved communities or with marginalized groups, but it also relates to the way in which we engage with the health system. Our willingness to involve ourselves in quality improvement, organize our practices to engage with populations, think beyond medicine to the social determinants of health, and choose wisely in our stewardship of health resources…all of these actions require engaging with the system beyond our individual practices and they are part of our social accountability.

The future of Canadian healthcare will be determined by the ways in which we – and ultimately our systems  - navigate tensions such as these. How we navigate them will be determined – in part – by how physicians navigate the balance between social accountability and self-interest.

It’s time for a new professionalism in medicine, one that is emerging in Canada and needs us to nurture it. It will be built not just on doctors’ devotion to patients nor on the advancement of our own interests, but on our willingness to be partners in a bigger system that is constantly responding to conflicting paradigms. In that future, physicians will be an integral a part of the complex system, rather than simply working alongside it.

About the Author(s)

Danielle Martin is a family physician in Toronto and Vice President, Medical Affairs and Health System Solutions at Women’s College Hospital. Her book, Better Now: Six Big Ideas to Improve Health Care for All Canadians, will be released by Penguin Random House in January 2017. For more on her book tour watch here and follow @docdanielle on Twitter.


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