Academic health science centres (AHSCs) are Canada’s high-performance vehicles for better health.
These are partnerships between a university with a medical school and its teaching hospital. While there are hundreds of hospitals in Canada, there are few AHSCs.
The doctors who work there are called academic physicians and they train Canada’s medical students and residents — providing the seed crop of doctors who will ultimately lead the provision of care to Canadians. They also provide complex care and perform research.
When well maintained, these medical centres propel us safely forward for years to come. However, if neglected and ignored, they may ultimately leave us sick and stranded at the roadside.
After assessing Canada’s AHSC, a national group called the Canadian Association of Professors of Medicine (CAPM) concluded that it’s time to fill the tank, change the oil and provide some tender loving care.
I would argue that academic medicine is currently experiencing the best of worlds and the worst of worlds. We possess new and powerful diagnostic and therapeutic tools and are poised to deliver more innovative care. However, our ability to accomplish these goals is challenged by a number of sociological, demographic and governmental factors.
This article aims to highlight these challenges, not as a complaint, rather to identify potholes in the road so that they can be avoided or repaired and we can accelerate our progress forward.
Research and specialized facilities
Academic health sciences centres conduct research — in the form of clinical trials (to test new drugs, devices and diagnostics), population health studies (to understand diseases at the population level) and translational research (to move basic science to the bedside and back again).
Research is a form of critical inquiry and discovery that generates the evidence upon which medical practise is based.
These doctors are also the experts who provide complex care for patients with life-threatening illnesses — including advanced surgeries, transplantation, catheter-based interventions to treat heart attacks and stroke and so much more. They also test the latest surgical techniques and interventions and evaluate new forms of molecular diagnostics.
The ASHC is also home to specialized and expensive core facilities including clinical laboratories, pharmacies and radiology programs (think PET scanners and MRIs) and interventional rooms (including robotic surgery suites, catheterization laboratories and the like) that support the community.
Congested hospital wards
To put into perspective how unique these organizations are, we can look at the numbers. Out of approximately 231 hospital sites in Ontario, only 16 are acute care academic centres and only five are fully-fledged AHSCs with medical schools.
These are located at McMaster University, University of Ottawa, Queen’s University, University of Toronto and Western University. Such classifications are however complicated, because the Northern Ontario School of Medicine also has a school of medicine and many of the features of an AHSC.
A 2010 report from the National Task Force on the Future of Canada’s Academic Health Sciences Centres concluded that AHSCs provide the majority of complex care in Canada.
However, one of the problems we face is the influx of Canada’s aging population of baby boomers into hospitals. Many of these people require alternate levels of care (ALC) and social support, rather than acute, tertiary care. But Canada lacks a comprehensive senior care network and in many hospitals in Ontario, ALC’s occupy 10 to 20 per cent of acute-care beds.
This, along with challenges such as the opioid crisis and homelessness, is congesting emergency departments and overcrowding inpatient wards. This compromises delivery of quality care and challenges physician wellness.
‘What makes dollars makes sense’
Academic health science centres are poorly understood by government. Often, to cater to public opinion, the government focuses on enhancing outpatient care, ignoring the importance of accessing state of the art, innovative care.
Compensation models are also misaligned with services provided. Most doctors in the community are paid on what we call a “fee for service” (FFS) payment plan. This means that they bill for each patient they see, for the service rendered.
This model disproportionately rewards clinical activity, particularly procedural activities, while failing to fund many important and time-consuming consultative services, and not funding research and educational activities at all.
At its worst this can lead to a culture where, “what makes dollars makes sense.”
Training pipeline goals at medical schools are also misaligned. While Canada needs large numbers of general practitioners, AHSCs need highly specialized physicians — cardiologists and cardiac surgeons, neurosurgeons and neurologists, gastroenterologists and general surgeons, nephrologists and transplant surgeons, laboratory medicine specialists, anaesthetists and radiologists. A focus on training more general internists is also important to the sustainability of our health-care system.
Finally, Canada lacks a funding mechanism to support the training of our most advanced learners, who are referred to as “fellows.” These are the doctors that go on to provide complex care such as coronary angioplasty, endovascular therapy for stroke, transplant medicine or catheter-based treatment of heart arrhythmias.
In the absence of fellowship funding, Canadian AHSCs rely increasingly on importing international medicine graduates to staff their hospitals.
No funding for outstanding research
Finally, we have inadequate research funding models. The creation of a clinician scientist takes approximately three additional years of postgraduate medical training. This is followed by five years as a junior faculty member, during which substantial time protection and mentorship are required.
This is difficult to provide when the rate of success for research proposals at Canada’s agency for funding biomedical research — the Canadian Institute of Health Research (CIHR) — is below 15 per cent.
Due to lack of funds, CIHR has been rejecting 80 to 90 per cent of funding applications, including those deemed outstanding by peer review. CIHR was intended to have a budget equal to one per cent of public health spending, but this has not kept up with health expenditures or inflation.
The 2017 Naylor report, from the expert panel on Canada’s Fundamental Science Review notes:
“Canada ranks well globally in higher education expenditures on research and development as a percentage of GDP, but is an outlier in that funding from federal government sources accounts for less than 25 per cent of that total, while institutions now underwrite 50 per cent of these costs with adverse effects on both research and education.”
The report recommended an increase in CIHR funding of, “$485 million, phased in over four years, directed to funding investigator-led research.” However, while some of the report’s recommendations were taken up in the 2018 Federal budget, many outstanding grants will continue to be unfunded.
The future is a federally-funded network
Alternate funding plans (AFPs) need to be considered, which reward activities in education, research and clinical care equally.
AHSCs also need more research funding — to enable the next wave of researchers to save lives. To achieve this they need an improved budget structure.
We should also create a federally funded network of accredited AHSCs. Although health care is primarily provincially funded, the federal government’s funding via the Canada Health Transfer accounts for approximately a quarter of the health-care budget.
Federal funding is both discretionary and growing (at a rate of around six per cent per year). This funding could be used selectively to develop, advance and unify a national network of AHSCs, in which academic departments of medicine could thrive.
With such investment we would certainly see benefits beyond improved health care.