A clinical education future worth working for Remarks by Angus Rae, M.B.FRCP To the 2009 AGM of the Section of Clinical Faculty, BCMA November 2, 2009

Why clinical teaching is growing and needs to grow For decades CF have taught students with their patients in recognized teaching hospital medical schools in an ‘unwritten amicable gentlemen’s agreement’ For decades CF have taught students with their patients in recognized teaching hospital medical schools in an ‘unwritten amicable gentlemen’s agreement’ Doctor shortage is now critical and growing. Doctor shortage is now critical and growing. Increasing demand on peripheral hospitals and GP offices for mentoring services Increasing demand on peripheral hospitals and GP offices for mentoring services Clinical faculty do 70% of UBC’s teaching Clinical faculty do 70% of UBC’s teaching BC is Canada’s heaviest user of clinical teachers BC is Canada’s heaviest user of clinical teachers Up to 3,000 clinical faculty now devote varying amounts of time to teaching while practicing medicine Up to 3,000 clinical faculty now devote varying amounts of time to teaching while practicing medicine

So what’s the problem? As the student numbers grew, little thought was given to the impact of more learners on CF teachers, their incomes, their office overheads, or their patients. As the student numbers grew, little thought was given to the impact of more learners on CF teachers, their incomes, their office overheads, or their patients. For years UBC has taken CF teachers/mentors for granted without a thought for a formal partnership – nor did any other university as far as I know. For years UBC has taken CF teachers/mentors for granted without a thought for a formal partnership – nor did any other university as far as I know. Nor in those days did CF consider it. Nor in those days did CF consider it.

UBC’s track record UBC’s track record  The FOM has said our forebears in traditional teaching hospitals taught freely and so should we; but their rewards were manifest – referrals by status and from well taught students. There was no income loss from  teaching as some of us were asked to bear.  Doctor shortage now critical: student enrollment 60 in 1968, 256 in 2009, 288 in Pressure on CF teachers increases  Hence this unwritten ‘Gentlemen’s agreement’ between CF and the FOM, teaching in return for status and hence referrals, is now obsolete  As the need for overworked unsalaried CF teachers rises office overheads increase, fewer CF can take on learners yet – 3 M Canadians have no Family doctor. 3 M Canadians have no Family doctor.  Good teaching takes time, time is money and fewer can afford it.

1998 -As pressure grew, CF reacted As pressure grew, CF reacted. Organized the University Clinical Faculty Association to: Organized the University Clinical Faculty Association to: Consider how best to handle the worsening relationship with the FOM Consider how best to handle the worsening relationship with the FOM Represent clinical faculty in dealings with UBC to ensure fair terms of work. Represent clinical faculty in dealings with UBC to ensure fair terms of work. Provide a ‘listening post’ for harassed members Provide a ‘listening post’ for harassed members

“…An autonomous, self-governing Clinical Faculty Association, within the community of the University, dedicated to good clinical medicine, clinical research and teaching, and able to negotiate in good faith with the Faculty of Medicine the conditions under which members would join their salaried colleagues as equal partners in the common enterprise of training future doctors and other health professionals” 1998: UCFA (now the Section of Clinical Faculty) proposed:

In 1995 FOM was in budget crisis From an external review of FOM finances, April 1995: “...morale is in danger of diminishing throughout the Faculty, but it is at a seriously low ebb amongst the clinical faculty who feel that they are not rewarded or recognized for what they do.” Facing a $5 million deficit, the Faculty of Medicine cut costs by: Not replacing full time faculty teachers/researchers (saving: $300,000 pa) Reducing teaching support staff (saving: $200,000 pa) Guess who filled both gaps? Guess who filled both gaps?

Resolution of City Wide Cardiology June : …the Division will not teach ….any undergraduate students ….until Funding for secretary restored Teaching assigned appropriately Firm agreement between Division and FoM Pro- 17; Con -1; Abs 2

“Mutual Responsibilities and Obligations for CF and the FOM” report which included: “Mutual Responsibilities and Obligations for CF and the FOM” report which included: ‘ Rights of CF’ one of which was: ‘ Rights of CF’ one of which was: “The Faculty of Medicine recognizes the right of Clinical Faculty members to form an association…. and recognizes the right the association to represent … Clinical Faculty.” As a result, Dean’s Task Force was formed. Resulted in unanimous 1999 agreement to accept:

Regrettably… Despite signing the agreement, UBC has never consistently honored it, especially its pledge to recognize UCFA Despite signing the agreement, UBC has never consistently honored it, especially its pledge to recognize UCFA Later an appointment/offer letter was mutually accepted but the FOM reneged on agreed payments to clinical faculty and were ordered by a distinguished arbitrator to pay several thousand $ for past teaching Later an appointment/offer letter was mutually accepted but the FOM reneged on agreed payments to clinical faculty and were ordered by a distinguished arbitrator to pay several thousand $ for past teaching

In place of partnership, UBC: Refused to negotiate directly with UCAF representing CF Refused to negotiate directly with UCAF representing CF Created advisory Clinical Faculty Affairs Committee, funded handsomely by the Deans office, to “represent” clinical faculty Created advisory Clinical Faculty Affairs Committee, funded handsomely by the Deans office, to “represent” clinical faculty  CFAC included several honorable CF members but, unelected by clinical faculty at large, were not truly representative.  Over time funds available in part from earlier UCFA pressure were distributed arbitrarily. But little transparency over funding UBC continue to rely on one-sided “appointment letters” that maintain a master-servant relationship to clinical faculty. UBC continue to rely on one-sided “appointment letters” that maintain a master-servant relationship to clinical faculty. Rumors abound connecting clinical privileges to teaching duties, although denied surfaced last week; voted down by medical staff Rumors abound connecting clinical privileges to teaching duties, although denied surfaced last week; voted down by medical staff

UCFA struggled to try and bring UBC to the table UCFA struggled to try and bring UBC to the table UBC clung to its strategy of rejecting partnership in favor of domination UBC clung to its strategy of rejecting partnership in favor of domination Pressure on clinical faculty to submit to one- sided agreements grew. Pressure on clinical faculty to submit to one- sided agreements grew. Result: Stalemate Result: Stalemate

When asked, BCMA agreed readily to provide assistance/representation to clinical faculty When asked, BCMA agreed readily to provide assistance/representation to clinical faculty BCMA Section of Clinical Faculty formed BCMA Section of Clinical Faculty formed 2008: “talks” (not “negotiations”) began between BCMA and Faculty of Medicine through joint committees 2008: “talks” (not “negotiations”) began between BCMA and Faculty of Medicine through joint committees

And since that time… 2008: Joint committees agreed to form a new contract/appointment letter (still a master-servant relationship between University and an individual clinician). 2008: Joint committees agreed to form a new contract/appointment letter (still a master-servant relationship between University and an individual clinician). ‘Accept or Resign’. Was this a threat? ‘Accept or Resign’. Was this a threat? No referendum of clinicians was held to determine their support for this No referendum of clinicians was held to determine their support for this 2009: BCMA commissioned IPSOS Survey to solicit opinions from BCMA members; results due in Nov. 2009: BCMA commissioned IPSOS Survey to solicit opinions from BCMA members; results due in Nov. BCMA will decide in November what stance to take toward new contract in 2010 BCMA will decide in November what stance to take toward new contract in 2010

Realities we face today University medical schools are obliged to train undergraduate students and in this involve clinical faculty, but have no mandate to control CF in any way in regard to patient care. University medical schools are obliged to train undergraduate students and in this involve clinical faculty, but have no mandate to control CF in any way in regard to patient care. From my experience, only in BC does academic faculty assume the right to dictate to clinical faculty. Elsewhere there are harmonious partnerships between academic faculty and clinicians. From my experience, only in BC does academic faculty assume the right to dictate to clinical faculty. Elsewhere there are harmonious partnerships between academic faculty and clinicians. The problem is one of principle. Clinicians caring for patients are beholden first to their patients. Any authority whose primary interest, however otherwise worthy, is other than patient care, must desist from interfering with the physician’s primary duty. The problem is one of principle. Clinicians caring for patients are beholden first to their patients. Any authority whose primary interest, however otherwise worthy, is other than patient care, must desist from interfering with the physician’s primary duty.

How we can move forward BCMA should: BCMA should: Continue its support to Clinical Faculty Continue its support to Clinical Faculty Explore the partnership proposed between CF & UBC from all angles, feasibility, practicality, financially and legality Explore the partnership proposed between CF & UBC from all angles, feasibility, practicality, financially and legality Without consideration of this proposal nothing will be achieved. Without consideration of this proposal nothing will be achieved. Support its Website pledge to “advance the health of British Columbians by working for the improvement of medical education…” Support its Website pledge to “advance the health of British Columbians by working for the improvement of medical education…” We know they will honor it. We know they will honor it.

Faculty of Medicine Faculty of Medicine There are good ideas and bad ideas but no idea unworthy of debate by a great university There are good ideas and bad ideas but no idea unworthy of debate by a great university What we are advancing is one idea, ARE we great enough to consider it? What we are advancing is one idea, ARE we great enough to consider it? For the sake of society, the system must change. For the sake of society, the system must change. We take no issue with those involved at the Faculty of Medicine, only with the outmoded system itself. We take no issue with those involved at the Faculty of Medicine, only with the outmoded system itself. Clinical Faculty: Clinical Faculty: Familiarize yourselves with the issues and the dangers of the status quo and support BCMA and its SCF in far greater numbers than before. Familiarize yourselves with the issues and the dangers of the status quo and support BCMA and its SCF in far greater numbers than before.

My parting message to everyone: It is now or never. It is now or never. Each of us is responsible for the future of our profession and the care of our patients. Each of us is responsible for the future of our profession and the care of our patients. Sincere thanks for your help. Hasta la Vista! Sincere thanks for your help. Hasta la Vista!