Gravitas. Reflections Nick Busing, President & CEO

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1 m. (feminine gravitatis) a quality of substance or depth m. (feminine gravitatis) caractère de ce qui a de l importance Association of Faculties of Medicine of Canada L Association des facultés de médecine du Canada Reflections Nick Busing, President & CEO This edition of Gravitas is all about data, and the articles within it all illustrate the important role data plays in the work of the Association of Faculties of Medicine of Canada (AFMC) and Canada s 17 faculties of medicine. AFMC has a long and proud history. Founded in 1943 in response to the need to increase the production of physicians in light of the Second World War, data has been central to its work since the beginning. During the postwar years, Canada s medical schools devoted much time and energy to integrating returning medical officers into civilian medical practice and coping with the influx of veterans, who comprised up to 25 per cent of entering classes. Postwar demands on the schools also focused attention on the need for nationwide planning and action, and the association became the repository for data on student applications and admissions. When I arrived at the association five years ago, one of my goals was to consolidate the various data and analysis functions under the leadership of a senior manager. Steve Slade now oversees several data-collecting and analysis initiatives which provide robust datasets and have positioned AFMC as a go-to organization for policy makers and planners seeking information pertaining to medical education and physician human resource issues. Data has truly become an integral part of the work we do. AFMC s Office of Research and Information Services (ORIS), collects and analyzes data pertaining to MD programs across the country enrolment, tuition, research activities, faculty counts, and graduate student numbers. More recently, ORIS has taken on collecting financial data pertaining to Canada s faculties of medicine. Canadian Post-MD Education Registry (CAPER) is a partnership of AFMC, the Medical Council of Canada, Volume 43 N o.4 December/ Décembre Evidence-based Advocacy Why data matters Irving Gold Importance of Data for Planning and Decision-Making Hussein Lalani and Joshua Tepper 7 8 On Road To Find Out Tom Feasby and Joanne Todesco Bridging the Data Gap Lynda Buske 9 11 Data for the Future Noura Hassan continued on page 2 Does Canada Need a National Diversity and Admissions Policy Regarding the MCAT? Mark Hanson and Barry Lavallee 265, avenue Carling Avenue, Suite/pièce 800, Ottawa, Ontario K1S 2E1 Tel/Tél. : (613) Fax/Téléc. : (613)

2 When I arrived at the association five years ago, one of my goals was to consolidate the various data and analysis functions under the leadership of a senior manager. Steve Slade now oversees several data-collecting and analysis initiatives which provide robust datasets and have positioned AFMC as a go-to organization for policy makers and planners seeking information pertaining to medical education and physician human resource issues. the College of Family Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, the Canadian Association of Interns and Residents, Health Canada, and all provincial and territorial governments (with the exception of Quebec). CAPER collects and analyzes data on residents and fellows as they go through post-md training, as well as data pertaining to where physicians ultimately chose to practise once they are licensed. Most recently, CAPER has expanded its database development to track international medical graduates as they enter into the myriad of steps required to obtain entry into post-md training or enter into practice in Canada. Another important development has been the increasing integration of data into our advocacy efforts. Under the leadership of Irving Gold, AFMC has significantly increased its advocacy activities and now regularly weighs in on issues of national importance. As his article in this edition points out, one of the strengths of our voice is its basis in evidence and our policy recommendations are driven by the data we hold. It is somewhat ironic that as I write this, the Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities is holding an in-camera session dealing with the impact of cancelling Canada s mandatory long-form census. As we indicated in our response to this decision, AFMC is concerned about this decision and the impact it will have on public policy deliberations in a wide range of areas. It seems that while AFMC and various arms of government are putting increased emphasis on data and analysis, there are those in government who would see us adopt the reverse strategy. It is our hope that Canada will continue to engage in evidence-based policy making and that governments continue to work with the rich data sets housed here at AFMC. From the CAPER-ORIS archives 1

3 President & Chief Executive Officer/ Président directeur général Nick Busing VP, Government Relations and External Affairs/ Vice-président, Relations gouvernementales et affaires externes Irving Gold VP, Research and Analysis CAPER-ORIS/ Vice-président, Recherche et analyse CAPER-ORI Steve Slade AFMC Executive Committee/ Comité Exécutif de l AFMC Chair & Treasurer/Président et trésorièr James Rourke, Memorial University of Newfoundland Chair-elect/Président désigné Thomas Feasby, University of Calgary Members-at-large/Membres Roger Strasser, Northern Ontario School of Medicine Catharine Whiteside, University of Toronto Committee on Accreditation of Canadian Medical Schools (CACMS)/ Comité d agrément des facultés de médecine du Canada (CAFMC) Chair/Président Abraham Fuks, McGill University Secretary/Secrétaire Nick Busing, AFMC Assistant Secretary/Adjointe secrétaire Linda Peterson, University of British Columbia Committee on Accreditation of Continuing Medical Education (CACME)/ Comité d agrément de l éducation médicale continue (CAÉMC) Chair/Président Marianne Xhignesse, Université de Sherbrooke Secretary/Secrétaire Nick Busing, AFMC Canadian Post-M.D. Education Registry (CAPER)/ Système informatisé sur les stagiaires post-m.d. en formation clinique Chair/Présidente To be announced / À suivre VP, Research and Analysis CAPER/ORIS/ Vice-président, Recherche et analyse CAPER-ORI Steve Slade (sslade@afmc.ca) Editor/Éditeur: Irving Gold Managing Editor/Coordonnatrice: Natalie Russ ISSN: Reflecting on Data Steve Slade, Vice President, Research and Analysis (CAPER-ORIS) AFMC Welcome to the data-themed issue of Gravitas. To pull this issue of Gravitas together we asked a broad sampling of guest writers to share their thoughts on data. We sought input from faculty of medicine deans and associate deans, health researchers, medical students and associations, governments and other leaders. A variety of questions were used to elicit the unique perspectives of our guest writers. For example, what data is of greatest relevance to you and how does it influence your decision making? Are there significant data gaps we need to fill? Looking forward, what metrics will you focus on to decide if the change we make today leads to the outcomes we expect to see in the future? Our only hard and fast rule was that invited articles be clearly linked to data and how it s used to guide our plans and decisions. I believe it s fair to say that one observation applies to all of our guest writer contributions: If you think data is dull, look again! reflections we received from our guest writers are insightful, at times visionary and always highly relevant to the leaders and managers of academic medicine, as well as those of the broader healthcare system. I d like to take a moment to highlight a couple of key messages and suggest how they will shape AFMC s future data and information activities. In their article entitled On the Road to Find Out, Drs Todesco and Feasby offer a wonderful analogy about the use of customized data dashboards. dashboard analogy is most apt, as data indicators can tell us where we ve been, the pace at which we re moving and the direction we re headed in. From the perspective of one who collects and disseminates data, the take home message is that many customized data dashboards are in use. We should expect the indicators on the postgraduate dean s dashboard to differ somewhat from those used by undergraduate deans. Similarly, the dashboards used by certifying bodies, licensing authorities, government, advocacy groups, and others will all be unique. In their article on Importance of Data for Planning and Decision-Making, Mr. Lalani and Dr. Tepper make the important point that we need to continually enhance our evidence base. Indeed, we do see enhanced evidence coming from health workforce planning models that account for population needs, rather than just looking at past healthcare utilization patterns. Drs Hanson and Lavallee make a related point in the context of data and information used as part of the MD program admissions process. Admissions data must be of the highest possible relevance and quality, as it is decisive in shaping the composition of Canada s future physician workforce. articles provide a couple of concrete examples of why we need to continually push for enhanced data inputs as part of the decision-making process. 2

4 AFMC Standing Committee Chairpersons/ Présidents des comités permanents de l AFMC Continuing Medical Education/ Éducation médicale continue Ford Bursey, Memorial University of Newfoundland Penny Davis, University of Saskatchewan Postgraduate Medical Education/ Enseignement médical postdoctoral Mark Walton, McMaster University Research and Graduate Studies/ Recherche et études supérieures Penny Moody-Corbett, Memorial University of Newfoundland Undergraduate Medical Education/ Enseignement médical prédoctoral Bruce Wright, University of Calgary AFMC Resource Groups/ Groups ressources de l AFMC Admissions and Student Affairs/ Admissions et affaires étudiantes Melissa Forgie, University of Ottawa Marc Moreau, University of Alberta Faculty Development/ Formation du corps professoral Kalyani Premkumar, University of Saskatchewan Equity, Diversity and Gender (EDG)/ Équité, la diversité et le genre (ÉDG) Gurdeep Parhar, University of British Columbia Global Health/ Santé à l échelle mondiale Lynda Redwood-Campbell, McMaster University Katherine Rouleau, University of Toronto Institutional Advancement/ Développement institutionnel Gail Brescia, Northern Ontario School of Medicine Kim Daynard, Northern Ontario School of Medicine Informatics/Informatiques Rachel Ellaway, Northern Ontario School of Medicine Libraries/Bibliothèques Suzanne Maranda, Queen s University Physician Health and Well-being/Santé et mieux-être des médecins Derek Puddester, University of Ottawa Professionalism/ Professionalisme Shiphra Ginsburg, University of Toronto Pier Bryden, University of Toronto Gravitas is the official quarterly newsletter of Association of Faculties of Medicine of Canada. Opinions expressed in this bulletin do not necessarily reflect the views of the Association. Contributions to Gravitas in either English or French are welcomed. Advertisements are also accepted. Gravitas is sent free of charge to members of the Association. Gravitas est le bulletin trimestriel officiel de l Association des facultés de médecine du Canada. Les opinions exprimées dans ce bulletin ne sont pas nécessairement celles de l Association. Les contributions à cette publication sont les bienvenues et peuvent être rédigées en français ou en anglais. Les annonces publicitaires sont également acceptées. In her article entitled Bridging the Data Gap, Ms. Buske reflects on developments that could help, or hinder, the data dashboards we rely upon. For example, declining survey response rates and privacy constraints may lead to data flight, which in turn affects the completeness and quality of our data and information. Moreover, clinicians continue to adopt the electronic health record (EHR) as a standard of care. However, if the EHR offers unprecedented potential to study antecedents of illness, co-morbidity, clinical decision-making, medical interventions, health epidemiology and health outcomes, we must ask how or even if health researchers will have access to this new data source. challenges are many, but so too are the potential solutions. As suggested by Ms. Buske, a universally-adopted system of anonymous unique identifiers will facilitate data sharing, and possibly open the way for health researchers to access new data. Mr. Lalani and Dr. Tepper also point to the utility of the unique identifier as an aid in cross-jurisdictional research. Certainly new solutions are needed to address the mounting problem of survey fatigue, possibly through merged surveys or the use of alternative, secondary data sources. From a data manager s perspective, we need to work closely with data providers in looking for solutions that address the emerging and inevitable challenges we ll face. Data is viewed from quite a different angle in Professor Knoppers article entitled Return of Individual Research Results: Why the fuss? article challenges us to think of personal data in its many forms and potential applications. In health and biomedical research, individual data has a longstanding role in the service of scientific validity, possibly leading to clinical utility. More recently, we can access our own individual data through private companies offering MRI, ultrasound and other biomedical testing services. Reflecting on the availability and complexity of one s own genetic profile, Professor Knoppers writes: General practitioners, confronted by their patients with print-outs on genetic susceptibility, are no better prepared than consumers to deal with what is exposed by whole genome sequencing and what it means Will the biological family (however defined), become the patient? Obviously, all general practitioners will need to be well-versed in the complexities of human genetics and familial dynamics. We live at a time when individuals are increasingly the owners of their data, whether it s an online bank account, university transcript or health record. As data and information become more accessible we are simultaneously called upon to become a more data-literate society. Finally, I want to underscore the importance of fostering an awareness and appreciation of data in the very early stages of one s medical career. In her article on Data for the Future, Ms. Hassan outlines some of the issues and concerns that are on the minds of Canada s future physicians. She calls for improved metrics to evaluate learning experiences and diversity among medical students. Data development is a long and ongoing process. It is also very rewarding to see new data take shape and, more importantly, to watch it drive the change we hope to see. Young physicians, who have a vision of tomorrow s healthcare system and how to gauge our progress toward it, need opportunities to become familiar and engage with our data resources. Sincere thanks are given to all of the guest writers for this data-themed issue of Gravitas. It s critically important for data managers to remain attuned to emerging information needs and update our data collection accordingly. We also need to package our data in ways that allow users to assemble their own customized data dashboards. reflections offered by our guest writers are the exact inputs data managers need to do their work. Again, thank you. 3

5 Evidence-based Advocacy Why data matters Irving Gold, Vice President, Government Relations and External Affairs Momentum Building for Interprofessional Health Education Accreditation of Interprofessional Health Education (AIPHE) initiative, funded by Health Canada, is a national collaborative of eight organizations that accredit pre-licensure education for six Canadian health professions: physical therapy, occupational therapy, pharmacy, social work, nursing and medicine. A national consultation gathering with key stakeholders for the six health professions, including clinical site managers, regulatory authorities, educators and government representatives, was recently held on November 8, 2010 via Webinar technology. se stakeholder groups are critical for enabling education programs to immerse students and new graduates in collaborative, patient/client-centred health and social care environments. Close to 500 stakeholders were originally invited. With the assistance of more than 25 facilitators, over 200 representatives participated in the gathering, conducted in English and French, from these 14 sites across the country: Vancouver, Victoria, Calgary, Edmonton, Saskatoon, Winnipeg, Toronto, Ottawa, Montreal, Sherbrooke, Quebec City, Halifax, Moncton, and St. John s. Preliminary feedback from the gathering suggests that there is widespread support for the draft (Accreditation) Standards Language and Assessment Guidelines as well as interest in a sustainable framework for implementation of interprofessional education principles, processes and practices. To ensure that the work being developed is shared more broadly, AIPHE will host a Knowledge Exchange Session with representatives of other health academic program accrediting organizations at the beginning of March For more information, visit or mshahin@afmc.ca Over the last several years, the AFMC has significantly increased its advocacy activities meant to inform and influence public policy in areas of relevance to our members. Our major areas of focus have been medical education, health human resource planning, and increased federal investments in science and technology. defining characteristic of our advocacy work has been its basis in the evidence. As this edition of Gravitas will illustrate, the AFMC can, and should be an important source of data and information to policy makers and planners. Data is very important to advocacy, particularly in the areas we focus on; our underlying messages are not ideological, or even philosophical in nature. Our advocacy work is about Canada making sound decisions that will ultimately serve Canadians well in terms of their health, the healthcare services they receive, and economically, through wise resource allocation decisions as well as innovations in research, science and technology and health service delivery. Backing up our advocacy asks with data allows us to trace the origins of our positions to their underlying assumptions and the data that has led us to assess the situations and propose solutions. Sound and credible data allow us to describe current issues, trends, realities, and propose solutions based on what we know as opposed to what we want or simply believe. Focussing on data protects us from the charge that we are simply advancing the goals of a special interest or professional group. It allows the recipients of our messages to come to the same conclusions as we have, following an internal and consistent logic that is clear and transparent. Another critical component of advocacy is the use of stories. Presenting aggregate data is important, but stories allow us to personalize issues and make them real. Advocating for increased investments in health and biomedical research has been a mainstay of our advocacy activities. And while it has been important for us to point to the data for example, the multiplier effect which illustrates how a dollar in research investments yields far more in increased economic activity, it has been equally important for us to employ stories to reinforce the data and make it more digestible. Our series titled impact does exactly this it takes the abstract argument that we need to continue to invest in faculty-based health and biomedical research and makes it real by telling the story of an important discovery that was made possible by Canadian investments in research that has had a tangible effect on the lives of Canadians. At our recent Deans on the Hill advocacy day, the importance of stories was made loud and clear. Decision-makers we met with demonstrated that they have an understanding of many of the complex issues facing our healthcare system. y have seen many of the numbers and datasets pertaining to our doctor shortage, for example, but what really resonated with them were the personal stories coming from constituents and others that have brought concerns to them. Our advocacy efforts will continue to incorporate solid data with compelling stories. And as always, we would love to hear from you. If you have a suggestion as to a compelling story we should incorporate into our advocacy work, please let me know by me at: igold@afmc.ca 4

6 Guest Editorial Hussein Lalani has worked for the Ministry of Health and Long-Term Care for twelve years, of which the last four he has spent leading a team of four professionals in the Health Human Resources Forecasting and Modelling Unit. main responsibilities of the unit include enhancing the data, research and analytical capacity of stakeholders and the ministry to engage in improved HHR planning in Ontario. Prior to joining the unit, Hussein addressed numerous OHIP provider payment issues and was responsible for managing the research and analysis of the utilization of health services by physicians and patients. He holds two undergraduate degrees in psychology and life sciences and a Master of Public Administration with specialization in health policy all from Queen s University. Joshua Tepper is a family physician and an Assistant Deputy Minister at Ministry of Health and Long-Term Care, Health Human Resources Strategy Division. As the Assistant Deputy Minister he leads the HealthForceOntario health human resources strategy. In this role, he also reports to the Ministry of Training, Colleges and Universities. He reports to the Premier on the Family Health Care for All health results table. With a degree in public policy from Duke University he has been involved in health policy and research relating to health human resources at both the provincial and national level. He was a senior medical officer for Health Canada, an adjunct scientist at the Institute for Clinical Evaluative Sciences (ICES) and a research consultant for the Canadian Institute of Health Information (CIHI). He completed his Masters of Public Health at Harvard University in Importance of Data for Planning and Decision-Making Hussein Lalani, Manager, Health Human Resources Forecasting and Modelling Unit, Ontario Ministry of Health and Long-Term Care Joshua Tepper, Assistant Deputy Minister, Ontario Ministry of Health and Long-Term Care and Department of Community and Family Medicine, University of Toronto In healthcare and even in the narrower area of health human resources (HHR) the issue of numbers rarely makes the front page or even the back page. Ironically, the most common questions asked of HHR policy makers are: How many do we have? and How many do we need? Answering these questions is complex, politically sensitive and arduous work. However it is critical work if we are going to ensure that every individual, today and in the future, has access to well-prepared healthcare providers when and where they are needed. Ontario HHR strategy is called HealthForceOntario (HFO). A major pillar of this strategy is to continually enhance our evidence base so we can engage in better planning. This started with improved data collection. For many years now, we ve had access to excellent data on physicians and good data on nurses, however for much of the other 40% of the regulated healthcare workforce we have known very little. Now, in partnership with the health regulatory colleges in Ontario, we have developed the Health Professions Database. This database captures a broad range of essential data about the demographic, geographic, educational and employment characteristics of all regulated healthcare providers. framework notes that planning health human resources based on system design and population health needs as opposed to relying primarily on past utilization trends will lead to more responsive health systems. We must also make better use of this data. Historically our approach to workforce planning was supply driven. More recently we have developed models that are driven by population demand. importance of a population-based approach is reflected by the 2007 Framework for Pan-Canadian Health Human Resources Planning. framework notes that planning health human resources based on system design and population health needs as opposed to relying primarily on past utilization trends will lead to more responsive health systems. In Ontario, working with the Ontario Medical Association, we have developed the Population Needs-Based Physician Simulation Model. This will help inform discussions of how many, and what types of physicians are needed in Ontario and where, to meet future population needs. model also allows for modelling of interprofessional teams. We have also funded research to estimate the supply of and requirements for registered nurses and registered practical nurses in Ontario. Incorporating a variety of factors that impact the nursing workforce such as education and training, population health needs, and productivity, this work can help us understand the impact of a variety of policy scenarios that can help alleviate the potential future shortages of nurses in Ontario. information 5

7 AFMC says goodbye to Dr. Jean Rouleau On December 1, 2010, Dr. Jean Rouleau ended his term as Dean of the Faculty of Medicine at l Université de Montréal. Over the years, Dr. Rouleau has been a tireless champion of AFMC and an invaluable source of ideas and inspiration to the AFMC Board of Directors. AFMC would like to extend our sincerest thanks to Dr. Rouleau and wish him all the best as he takes on new challenges. from these evidence-based tools will be enriched with other types of information to inform decision-making. Further challenges remain. One challenge is recognizing the national and in fact global nature of the health workforce. Medical Identification Number for Canada (MINC) and the National Unique Identifier Project are programs that will assign a lifelong, non-reusable identifier to physicians and other providers to help healthcare planners understand national mobility patterns. Another critical challenge is that provider supply and population need are two corners of an important triangle. third corner is the service environment where patient and providers interact. We need to link our population-based planning models to health system planning in order to ensure that the right infrastructure and models of care delivery are in place to support current and new providers. While perhaps not the sexiest of health care topics, robust HHR data and modelling will help ensure a sustainable healthcare system where patients receive high quality and timely care. FMEC postgraduate project launches website We are pleased to announce the launch of the new website for the Future of Medical Education in Canada Postgraduate (FMEC PG) Project. Please click on for the latest information on the project, in English and in French. We welcome any comments and encourage you to visit the website often for updates. Le projet de l AEMC en éducation médicale postdoctoral a lancé un site Web Nous sommes ravis de vous faire part du lancement de notre nouveau site Web sur le projet postdoctoral sur l Avenir de l éducation médicale au Canada (AEMC EMPo). Veuillez cliquer sur pour obtenir les toutes dernières nouvelles sur le projet, tant en français qu en anglais. Vos commentaires sont les bienvenus. Nous vous encourageons à consulter souvent le site Web pour demeurer au fait des dernières nouvelles. 6

8 Deanery On Road To Find Out Joanne Todesco, Associate Dean, Postgraduate Medical Education, Faculty of Medicine, University of Calgary Tom Feasby, Dean, Faculty of Medicine, University of Calgary Tom Feasby is Dean of the Faculty of Medicine at the University of Calgary. He graduated from the University of Manitoba and trained in neurology and research at the University of Western Ontario and the Institute of Neurology, Queen Square. As department chair, he helped build the Department of Clinical Neurosciences at the University of Calgary into a national leader. From 2003 to 2007 he was the vice president of academic affairs at Capital Health in Edmonton and associate dean of clinical affairs in the Faculty of Medicine and Dentistry at the University of Alberta. Dr. Feasby is a specialist in neuromuscular disease and has made significant contributions to the understanding and treatment of the demyelinating neuropathies, especially Guillain-Barré Syndrome. His current research focuses on the appropriateness and effectiveness of healthcare interventions. Recent projects have studied carotid endarterectomy, intravenous immunoglobulin and MRI. Joanne Todesco is an alumnus of the University of Calgary medical school Class of 1980 (Chameleons). She holds double fellowship with the Royal College of Physicians and Surgeons of Canada in internal medicine and anesthesiology. In her position as associate dean for PGME she oversees program delivery and maintenance of accreditation of 61 residency programs in which over 700 trainees are currently enrolled. She has led a number of provincial initiatives and currently serves as chair of the Alberta International Medical Graduate Steering Committee. Dr. Todesco is a current fellow in the prestigious Executive Leadership for Academic Medicine program at Drexel University in Philadelphia, PA. information superhighway that was envisioned in the 1990s has materialized as a multi-lane, high-speed labyrinth. route is cluttered with highly valuable data, but littered with distractions, outdated signage, and the indecipherable. In this environment, faculties of medicine need to filter information in some way in order to make it useful for navigation and communication. When we ask our leaders what data they use to drive their activities, it s clear that for the most part, they attend to a select information set. For example, in postgraduate medical education (PGME) there is always an eye on resident numbers relative to capacity in the various programs, CaRMS match information, resident performance, accreditation status, budgets, and workforce requirements. Borrowing from an apt business model, these indices could be considered the elements of the PGME dashboard. By recognizing and focusing on these dashboard items, the PGME office directs its attention, resources, and communications meaningfully. Future needs and types of data can be viewed in terms of how, or if, they contribute to the existing dashboard instrumentation. model can be stretched further to consider the positioning of data from the perspective of the driver. Data viewed through the rear window tells us where we ve come from, sometimes pointing to better routes that could have been taken, and influences that can only be seen in hindsight, for example the effect of new technologies on surgical specialty practice. scenery viewed through the side windows reflects the external environment and reminds us of the prevailing culture of our organizations. At the University of Calgary this might include the current price of oil and indicators of diversity among our student populations. Through the front windshield we examine our projections and the road ahead, for example the implications of a growing geriatric population. In order to populate our dashboards, we depend upon reports generated by partner organizations such as the AFMC, CaRMS, the colleges, health regions, and governments; and rely heavily upon our financial officers. As the need for additional information evolves over time, we also require plasticity and responsiveness in our databases to incorporate new inputs and queries. Most importantly, we depend on our faculty and staff to work with data both at the detailed, number-crunching level and from the bigger perspective of overall trends and patterns. use of a common metaphorical lens can help us filter out the traffic, think in terms of a shared roadmap despite our multiple and complex missions, and steer us toward a common destination. 7

9 Guest Editorial Lynda Buske has been with the Canadian Medical Association since 1992 and is currently Director of Workforce Research in the CMA s Canadian Collaborative Centre for Physician Resources (C3PR). Prior to joining CMA she gained extensive experience in the Health Information Division of Health Canada in the development of the National Physician Data Base. At the CMA, Ms. Buske s responsibilities include ongoing physician survey research such as the National Physician Survey and the development of physician resource planning tools for projecting future supply. She serves as an expert resource to other medical organizations and bodies such as the Canadian Institute for Health Information, the Canadian Medical Forum and the Canadian Post-MD Education Registry. Ms. Buske holds a Bachelor of Science degree in Mathematics from Carleton University. Bridging the Data Gap Lynda Buske, Director, Workforce Research, Canadian Medical Association In the last couple of decades I believe we have made good progress in health human resource databases with respect to collecting information on professions where we had large data gaps. I m not certain, however, that we ve made much progress in the comprehensiveness or accuracy of national level data related to physician resource issues. I think the strength of physician data today is the fact we now have powerful longitudinal information on students, residents and practising physicians which is the envy of other countries. However, we have in fact been experiencing some data flight issues among the major national physician databases on characteristics such as gender and age due to privacy concerns. Other proposed variables such as ethnicity, place of birth and aboriginal status remain politically difficult to collect. Historical indicators produced by the Canadian Institute for Health Information (based on physicians who bill on a fee-for-service basis) are now under serious review because the lack of information related to alternate payment models (representing 25% of clinical earnings) are rendering their use limited in representing the Canadian physician pool. Survey research has been an effective way of collecting both longitudinal information on various aspects of physician practice as well as data on very topical issues of the day. Response rates for physician surveys unfortunately have fallen drastically over the years and it is now difficult to get rates of even 30% compared to over 80% twenty years ago. Today it is very easy and cheap to mount on-line surveys with commercial tools and that means many more researchers, marketers, students, medical organizations and associations are doing so, often multiple times a year. It is not unheard of for physicians to receive up to 5 surveys per day! Lower response rates can lessen the ability to conduct sub-cohort analyses such as by age, sex, location, etc. To counteract this, researchers are going out to large numbers since cost is not a huge deterrent; this again increases the number of times an individual physician is contacted. Whether or not on-line survey research continues to be a viable method for serious research or becomes appropriate only for quick finger-on-the-pulse type polls remains to be seen. Technology has facilitated the collection and manipulation of large databases as well as streamlining the submission of raw data to national holdings. However, it is not evident to me that it has enabled more comprehensive data to be made available to researchers. establishment and adoption of the Medical Identification Number of Canada has the ability to facilitate data sharing but it will not result in new information if privacy issues trump cross organizational linkages. Data collection and analysis continue to be a key element of evidence-based policy development and the future potential to share information with electronic health records and unique identifiers is huge. Hopefully, with clear links between survey research and advocacy activities we will also continue to hear back from physicians on issues of interest to them. I d like to think that with the aid of collaborative efforts and technology, we are perhaps at the beginning of a period where new information can be appropriately gathered, shared and utilized while protecting the privacy of individual physicians. 8

10 Guest Editorial Noura Hassan is a third year medical student at McGill University. She is currently the Vice- President Medical Education of the Canadian Federation of Medical Students (CFMS) for the term and she previously served on the CFMS Executive Council as Quebec Regional Representative for With this portfolio comes many roles and responsibilities, including representing the voice of Canadian medical students within the CMA Committee on Education and Professional Development, serving on the CaRMS Board of Directors, and contributing to the RCPSC Committee on Education. In addition to contributing to discussions and decision-making processes related to medical education, Noura works on CFMS member-mandated projects related to medical education. Data for the Future Noura Hassan, VP Medical Education, Canadian Federation of Medical Students Amidst the saga resulting from the federal government s decision to abolish the mandatory long-version of the population census, the value of data was made evident to the general Canadian population. rich discussion that stemmed from this potentially dry topic was truly refreshing; data is the new hot topic! In this context and given my passion for medical education, I eagerly jumped on the opportunity to contribute to this edition of the AFMC Gravitas newsletter on behalf of CFMS. Though I am still relatively green in the medical profession, I have the great pleasure of beginning my career and being actively involved in medical education at an exciting turning-point. With the Future of Medical Education in Canada (FMEC) undergraduate project finalized and the FMEC postgraduate project well underway, I see great potential for change and evolution of our medical education system. I hope to be active in the implementation process that will help bring FMEC recommendations to life. Data plays a key role in any decision-making process, in project development, implementation and quality-assurance monitoring. In this piece, I will briefly address a few areas where data could be used to help improve medical education and healthcare delivery. One of the major issues in undergraduate medical education is capacity. In the past 10 years, there has been a phenomenal increase in medical school admissions. Canadian medical faculties have had to find solutions to accommodate this rapid influx of students without compromising the quality of our educational experience. AFMC s Study of Clinical Teachers in Canadian Faculties of Medicine: A 2009 Discussion Paper highlights the impact this increase has had on clinical teachers, both in academic centres and distributed medical education (DME) sites. report indicated that the increasing number of students has increased the workload of clinical teachers, making clinical teaching more burdensome. We need more data to help us understand the major stressors that lead to these realities. Objective data reporting the learner-to-teacher ratio in a given clinical rotation is lacking. This information should be sought not only from staff clinical teachers, but also from residents and medical students. Collection of this data would serve multiple purposes; this information can help paint a clearer picture of learners educational experiences in addition to serving as a tool to evaluate the performance of clinical teachers, including residents. Furthermore, the lack of support made available to DME satellite campus teachers and imposed clinical teaching tasks at community-based DME sites were reported in the 2009 study. More data must be made available to help address these issues as they may have a deleterious impact on the educational experience of Canadian medical students and residents in the context of ever-increasing popularity of DME. Better understanding of the challenges experienced at DME sites, from both a student and faculty point of view, will help develop and maintain the quality of the educational experiences at these sites that will in turn help alleviate the burden of capacity. Finally, I would like to address the importance of tracking data on the diversity in medicine and the impact it has on healthcare delivery. It has been shown that a representative 9

11 workforce is more likely to respond to the healthcare needs of its population. CFMS has championed the advocacy efforts for a physician workforce that is more representative of the Canadian population; we are proud to see that this message is being heard and acknowledged by key stakeholders in the medical community. Moving forward, we need to collect data that will help identify the real and perceived barriers to medical education. This will allow for implementation of an optimal action plan to effectively increase diversity in the Canadian physician workforce. It would also be necessary to track the impact of increasing diversity on healthcare delivery. Studies have shown that individuals from low socio-economic backgrounds are more likely to serve patients from said communities. Likewise, individuals from rural backgrounds are more likely to practise medicine in rural communities. Both aforementioned population subsets have also been shown to be 2.5 times more likely to choose family medicine as a field of practice than students from upper-middle class urban backgrounds. Prospective analysis of the impact that physician diversity program implementation has on Canadian healthcare delivery would be of great interest to academic leaders. This process would serve multiple purposes and would allow for evaluation of the efficacy of the program. Furthermore, the study could be designed in a way that allows for the collection of data that helps identify key variables in medical students career decision-making process. This information can then be used to tailor educational experiences to help direct students career choices, thus ensuring that future generations of physician workforces respond to the healthcare needs of the Canadian population. Deans on the Hill 2010 On Tuesday, October 5th, 2010, the Association of Faculties of Medicine of Canada (AFMC) held its second annual Deans on the Hill lobby day on Parliament Hill. event was a resounding success and saw AFMC staff and deans of medicine from across the country meet and discuss issues of national importance with 50 members of parliament and senators from all four major political parties. AFMC came to the hill with proposals relating to health human resource planning, increasing the diversity of medical students and Canada s physician workforce, strengthening health and biomedical research in Canada, and rebuilding Haiti s faculties of medicine. Find out more about Deans on the Hill 2010 by visiting our website at: advocacy-deans-e.php Participants of the 2010 Deans on the Hill from left to right, top row: Cathy Whiteside, William Albritton, Mark Walton, Steve Slade and Iain Young; middle row: James Rourke, Philip Baker, Nick Busing and Jacques Bradwejn; bottom row: Sarita Verma, Irving Gold, Penny Moody-Corbett and Gavin Stuart. 10

12 Mark Hanson is Associate Dean for Undergraduate Medicine Admissions and Student Finances at the Faculty of Medicine, University of Toronto. He recently assumed the role of the Association of Faculties of Medicine of Canada (AFMC) co-chair of the Indigenous Physicians Association of Canada (IPAC)-AFMC Retention and Recruitment Committee. In addition, he represents the University of Toronto medical school on the IPAC-AFMC Indigenous Health Educators Working Group and the National Indigenous Health Sciences Circle. Dr. Hanson is an associate professor within the Department of Psychiatry at the University of Toronto and staff psychiatrist at the Hospital for Sick Children. He received both his undergraduate medical education and postgraduate medical education in psychiatry at the University of Toronto. Barry Lavallee is a member of the Salteaux/ Métis communities of Manitoba. He is President of the Indigenous Physicians Association of Canada and currently practising family medicine half-time at the St. James Street Medical Clinic and Hope Centre Health Care. Dr. Lavallee is also the newly appointed Director of the Centre for Aboriginal Health Education through the Faculty of Medicine at the University of Manitoba where he is a leader in developing and establishing processes for building capacity to meet the academic, professional development and social support needs of Indigenous students. Additionally, Dr. Lavallee is the Director of Care and Treatment for First Nations Inuit Health within Manitoba. Dr. Lavallee graduated from the University of Manitoba and completed his post-graduate training in family medicine with an emphasis on rural/indigenous health. He completed his Masters of Clinical Sciences in Family Medicine at the University of Western Ontario. 1. Future of Medical Education in Canada (FMEC): A Collective Vision for MD Education, AFMC. 2. Dhalla IA, Kwong JC, Streiner DL, et al. Characteristics of First-Year Students in Canadian Medical Schools. CMAJ, 2002, 166(8) pp Does Canada Need a National Diversity and Admissions Policy Regarding the MCAT? Mark D. Hanson, Associate Dean, Undergraduate Medicine Admissions and Student Finances, Faculty of Medicine, University of Toronto Barry Lavallee, President, Indigenous Physicians Association of Canada Future of Medical Education in Canada (FMEC): A Collective Vision for MD Education report recommends enhancement of admissions processes with specific attention directed to recruitment, admissions and matriculation of students from under-represented groups leading to a medical student body more reflective of the diversity in Canada s population 1. A significant disparity has been reported between Canada s population and the ethnic and socioeconomic backgrounds of medical students 2. Most notably, Aboriginal peoples of Canada, Black Canadians, and students from rural and lower socio-economic status are under-represented in medical schools 2. Medical College Admissions Test (MCAT) is synonymous with medical school admissions as virtually all American medical schools and the majority of Canadian medical schools use the test within their admissions processes 3. Given its decision-support role, a review of MCAT data use across Canada is warranted, particularly in the context of the FMEC Collective Vision. MCAT scores function as a significant data input to the medical school admissions process. MCAT is required by 11 out of 17 of Canada s faculties of medicine. Northern Ontario School of Medicine (NOSM), University of Ottawa and Quebec s four medical schools comprise the six schools that do not use the MCAT. Language, access and admissions issues facing Indigenous Canadians and geography constitute the range of factors considered by these schools regarding their use of the MCAT. NOSM established admissions policies based upon these factors 4 and recently McGill discontinued the use of the MCAT due to concerns of bias towards Francophone medical school applicants 5. Important to the geography factor are the locations of MCAT testing centers 6. y are located in nine provinces. Prince Edward Island is the lone province without a center as are Canada s northern territories; the Northwest Territories, Nunavut and the Yukon. In addition, for those medical schools using the MCAT, many employ flexibility in MCAT score thresholds for admissions decisions regarding self-declared Aboriginal student applicants 7. use of the MCAT across Canada represents a mosaic reflective of Canada s history and its geography. Of note, this brief review of MCAT use did not elucidate factors potentially important for other under-represented student groups such as Black Canadians and those from lower socio-economic backgrounds. To return to the aforementioned FMEC recommendation calling for enhancement of admissions policies specific questions spring to mind: Should Canada s medical schools reflect upon their collective use of the MCAT? Does this MCAT mosaic maximize our collective diversity efforts to recruit, admit and graduate the growing numbers of physicians necessary to meet the diversity of healthcare needs across Canada s population groups? To answer these questions, is the time appropriate for engagement in a dialogue regarding a national diversity and admissions policy for MCAT use to further the FMEC goal of enhanced admissions? Certainly the FMEC report proposed national collaboration as a key enabler of transformational change 1, so it would appear that the time for such national dialogue is not only now but to be encouraged Medical School Admissions Requirements (MSAR). Association of American Medical Colleges. 4. Chapter 5. Designing an Admissions Process for the Northern Ontario School of Medicine by Jill Konkin, pp Making of the Northern Ontario School of Medicine. A Case Study in the History of Medical Education. Edited by Geoffery Tesson, Geoffery Hudson, Roger Strasser, and Dan Hunt. 5. Kondro W. McGill Scuttles MCAT. CMAJ. 2010; 182(13): E MCAT Testing Center Locations AAMC. Retrieved from sitelisting. 7. Summary of Admissions and Support Programs for Indigenous Students at Canadian Faculties of Medicine. Indigenous Physicians Association of Canada/ Association of Faculties of Medicine of Canada. March 2008.

13 IMGs in Canada Project Phase II: Measuring Progress Paromita Deb-Rinker, Project Manager, National IMG Database, CAPER Linda Bourgeois, Research Associate, National IMG Database, CAPER Steve Slade, Vice President, Research and Analysis (CAPER-ORIS), AFMC International Medical Graduates (IMGs) make important contributions to the health of Canadians and the role and impact of IMGs have surfaced in numerous systematic evaluations of the Canadian healthcare system in the last few decades. In response to one of the six recommendations of the Canadian Taskforce on Licensure of IMGs to develop the capacity to track and recruit IMGs, the Canadian Post-M.D. Education Registry (CAPER) 1 began work on the National IMG Database in goal of the National IMG Database is to compile longitudinal data that measures the flow of International Medical Graduates as they acquire credentials and eventually contribute to the Canadian physician workforce. Phase I of the National IMG Database project focused on building a data-sharing partnership among all agencies that IMGs encounter as they progress towards medical licensure in Canada. Phase II of the National IMG Database started in November 2009 as part of the IMGs in Canada Project. effort has been supported by AFMC 2 and the Foreign Credentials Recognition Division of Human Resources and Skills Development Canada. 3 This phase will strive to maintain and build upon the foundational database that was established through the Phase I partnership. It will also push towards a collaborative analytical agenda that supports the information and dissemination needs of data providers, planners, decision-makers and other stakeholders. Each data contributor adds a unique and critical component to the database. Data providers include the 17 faculties of medicine, 4 the Medical Council of Canada (MCC), 5 the College of Family Physicians of Canada (CFPC), 6 the Royal College of Physicians and Surgeons of Canada (RCPSC), 7 Collège des médecins du Québec (CMQ), 8 provincial and territorial regulatory authorities 9 and IMG assessment and training centres 10. second annual National IMG Database Report has just been published. 11 Similar to the first report, this edition provides a comprehensive statistical overview of the number of IMGs passing Canada s assessment, training, examination, certification and licensing processes. A few examples of data tables presented in this report include the number and types of licenses issued, gender, country/ continent of M.D. graduation, specialties and certification status of IMGs. Figure 1 provides a snapshot of the number of International Medical Graduates who got certified between 2005 and 2009, through one of the three certifying bodies in Canada. References: 1 Canadian Post-M.D. Education Registry (CAPER), 2 Association of Faculties of Medicine of Canada (AFMC), www. afmc.ca. 3 Foreign Credential Recognition Program, programs/fcr/overview.shtml. 4 Representing every Canadian faculty of medicine, the17 Faculties of medicine (from east to west) are members of the Association of Faculties of Medicine (AFMC). For more information, see www. afmc.ca/faculties-e.php 5 Medical Council of Canada (MCC), 6 College of Family Physicians of Canada (CFPC), 7 Royal College of Physicians and Surgeons of Canada (RCPSC), 8 Collège des médecins du Québec (CMQ), 9 Provincial and territorial regulatory authorities, medical.org/links/provli_e.php. 10 Assessment and training centres related_programs_imgs.shtml. 11 National IMG Database Report ( ), caper.ca/docs/pdf_2005_2009(1)_img_dbase_report.pdf. Note: We started collecting data from the Royal College from

14 References: 12 FMRAC Agreement on National Standards, on.ca/registration/default.aspx?id= Labour Mobility, labourmobility/labourmobility.shtml. 14 Pan-Canadian Framework, workplaceskills/publications/fcr/pcf_folder/section_2_01.shtml. 15 National Assessment Collaboration, research/national_assessment_collaboration.shtml. analysis, evaluation and decision-support goals of the IMGs in Canada Project are most timely. re are currently more than 60 different combinations of qualifications that entitle individuals to be licensed as physicians in various Canadian jurisdictions. 12 Not surprisingly, developments like Chapter 7 of the Agreement on Internal Trade (AIT) 13 and the Pan-Canadian Framework for the Assessment and Recognition of Foreign Qualification 14 are driving change within the regulatory environment. For example, the Federation of Medical Regulatory Authorities of Canada and the MCC are developing a national process of application for medical registration in Canada. MCC has also partnered with Canada s IMG assessment centres and other stakeholder organizations on the National Assessment Collaboration, 15 which will bring greater standardization to IMG assessment for entry to postgraduate medical education. It is clear that there is a rapidly changing environment of policies and initiatives that affect IMGs. It is critically important that we evaluate whether these changes are creating a more navigable system for IMGs, while simultaneously improving access to high quality physician care. Future studies of the IMGs in Canada Project will tell us if system changes benefit IMGs and the patients who require their care. Réflexions Nick Busing, Président-directeur général La présente édition de Gravitas porte sur les données. Les articles qui la composent illustrent tous le rôle important que jouent les données dans le travail de l Association des facultés de médecine du Canada (AFMC) et des 17 facultés de médecine canadiennes. goal of the National IMG Database is to compile longitudinal data that measures the flow of International Medical Graduates as they acquire credentials and eventually contribute to the Canadian physician workforce. Phase I of the National IMG Database project focused on building a data-sharing partnership among all agencies that IMGs encounter as they progress towards medical licensure in Canada. Phase II of the National IMG Database started in November 2009 as part of the IMGs in Canada Project. effort has been supported by AFMC 2 and the Foreign Credentials Recognition Division of Human Resources and Skills Development Canada. 3 This phase will strive to maintain and build upon the foundational database that was established through the Phase I partnership. It will also push towards a collaborative analytical agenda that supports the information and dissemination needs of data providers, planners, decision-makers and other stakeholders. Fondée en 1943 afin de former davantage de médecins durant cette période marquée par la Seconde Guerre mondiale, l AFMC se targue de posséder une longue et fière histoire. Dès ses débuts, les données sont au centre de son travail. Dans les années qui suivent la guerre, les facultés de médecine canadiennes consacrent beaucoup de temps et d énergie à intégrer les médecins militaires à la pratique médicale civile et à composer avec l afflux de vétérans qui constituent jusqu à 25 p. cent des classes entrantes. Les exigences d après-guerre sur les facultés orientent également l attention sur l importance de la planification et de l action à l échelle nationale. L Association devient donc le dépositaire des données relatives aux demandes d inscription et à l admission des étudiants. Les archives de CAPER-ORI À mon arrivée au sein de l Association il y a cinq ans, je m étais donné pour objectif de consolider les diverses données et fonctions d analyse sous le leadership d un gestionnaire principal. Steve Slade coordonne maintenant plusieurs initiatives de collecte et d analyse de données qui fournissent de solides ensembles de données et ont fait de l AFMC un organisme vers lequel se tournent les décideurs et les planificateurs à la recherche de renseignements relatifs à l éducation médicale et aux questions touchant les ressources humaines en santé. Les données sont véritablement devenues une partie intégrale de notre travail. 13

15 À mon arrivée au sein de l Association il y a cinq ans, je m étais donné pour objectif de consolider les diverses données et fonctions d analyse sous le leadership d un gestionnaire principal. Steve Slade coordonne maintenant plusieurs initiatives de collecte et d analyse de données qui fournissent de solides ensembles de données et ont fait de l AFMC un organisme vers lequel se tournent les décideurs et les planificateurs à la recherche de renseignements relatifs à l éducation médicale et aux questions touchant les ressources humaines en santé. L Office de recherche et d information (ORI) de l AFMC recueille et analyse des données relatives aux programmes de premier cycle en médecine de l ensemble du pays inscription, droits de scolarité, activités de recherche, membres du corps professoral et nombre d étudiants diplômés. Récemment, l ORI a commencé à recueillir des données financières afférentes aux facultés de médecine canadiennes. Le Système informatisé sur les stagiaires post-m.d. en formation clinique (CAPER) est un partenariat composé de l AFMC, du Conseil médical du Canada, du Collège des médecins de famille du Canada, du Collège royal des médecins et chirurgiens du Canada, de l Association canadienne des médecins résidents, de Santé Canada et de tous les gouvernements provinciaux et territoriaux (à l exception du Québec). CAPER recueille et analyse des données sur les résidents et les boursiers alors qu ils suivent une formation postdoctorale, ainsi que les données sur le lieu où ils choisissent d exercer une fois accrédités. Dernièrement, CAPER a élargi le développement de sa base de données pour faire un suivi des diplômés internationaux en médecine alors qu ils amorcent la multitude d étapes requises pour être admis dans le cadre d un programme de formation postdoctorale ou pouvoir commencer à exercer au Canada. Au rang des développements d importance, on compte l intégration accrue de données dans le cadre de nos efforts de défense des droits et intérêts. Sous le leadership d Irving Gold, l AFMC a sensiblement augmenté ses activités dans le domaine et se prononce désormais régulièrement sur des questions d importance nationale. Comme le fait remarquer un article de la présente édition, l une de nos forces, c est que nos interventions sont fondées sur des données probantes et que nos recommandations stratégiques sont sous-tendues par les données dont nous disposons. Il est un peu ironique que, pendant que je rédige cet article, le Comité permanent des ressources humaines, du développement des compétences, du développement social et de la condition des personnes handicapées anime au même moment une séance à huis clos sur l impact de la suppression du questionnaire de recensement canadien détaillé. Comme nous l avons indiqué dans notre réponse à cette décision, l AFMC est préoccupée par cette décision et son incidence sur les délibérations d intérêt public dans une vaste gamme de secteurs. Il semble que bien que l AFMC et les diverses branches du gouvernement mettent davantage l accent sur les données et l analyse, certains membres du gouvernement aimeraient que nous adoptions la stratégie inverse. Nous espérons que le Canada continuera à s engager dans la formulation de politiques fondées sur des données probantes et que les gouvernements continueront à travailler avec les riches bases de données qu abrite l AFMC. Séance d information stratégique de l AFMC : Base de données nationale sur les DIM L AFMC, de concert avec CAPER (Système informatisé sur les stagiaires post-m.d. en formation clinique), a animé une fructueuse séance d information stratégique le mardi 7 décembre 2010 sur le rôle que jouent les diplômés internationaux en médecine (DIM) dans notre système de soins de santé. Dans le cadre de cette séance d information stratégique, on a également présenté de nouvelles données découlant du projet de Base de données nationale sur les DIM. Pour de plus amples renseignements sur cette séance d information, veuillez cliquez ici : AFMC Policy Briefing: National IMG Database AFMC, along with the Canadian Post- M.D. Education Registry, held a successful policy briefing on Tuesday, December 7, 2010 on the role International Medical Graduates play in our healthcare system. policy briefing also presented newly-mined data from the National IMG Database project. For more information on this briefing visit: 14

16 A Word from CIHR Alain Beaudet, President, Canadian Institutes of Health Research Dr. Alain Beaudet, MD, PhD, is the President of the Canadian Institutes of Health Research (CIHR). As President, Dr. Beaudet acts both as Chair of the Governing Council and Chief Executive Officer of CIHR. Before joining CIHR in July 2008, Dr. Beaudet was the President and Chief Executive Officer of the Fonds de la recherche en santé du Québec (FRSQ), a position held since I worship at the altar of data a physician-scientist recently told me. Indeed, evidence-based practice relies on solid, reproducible data. However, while we like to believe that our healthcare system rests on data acquisition and application, the seductive shadow of empiricism never lurks far behind. Take, for example, the article Quelles maladies peut-on traiter par l homéopathie, published in the November 17th issue of L actualité médicale, a newspaper widely distributed to the Quebec medical profession. It recommends resorting to the likes of Aconitum, Arsenicum Alba or Camphora for treating a variety of disorders, an approach shown to be entirely inefficacious in all of the double blind randomized studies in which it was investigated. A notable exception was the controversial Nature article on the memory of water which was later to be withdrawn not surprising, mind you, since any therapeutic effect at the dilutions used would mean that we would have to revisit Avogadro s number! More seriously, one has to be concerned by the eagerness with which some physicians have embraced the recent liberation treatment proposed by the Italian physician, Dr. Paolo Zamboni, for multiple sclerosis (MS). One also has to be disappointed by the timid response of many professional associations to this challenge to evidence-based practice (the AFMC and the Canadian Medical Association being two notable exceptions). Admittedly, there are data in support of Dr. Zamboni s claim. But these data are neither robust nor reproducible. Yet, demand for the treatment exploded as soon as knowledge of it became public. This puts physicians in a difficult position, with patients wanting access to a treatment that isn t supported by evidence. And evidence is not easy to obtain in this case; we do not even know how to reliably diagnose the cerebrospinal venous insufficiency that is purported to lie at the root of the problem. Nonetheless, the research process is unfolding as it should. Canadian and American MS societies have funded clinical research investigating the association, if any, between stenosed neck veins and MS. An expert panel is monitoring that research to determine whether the results will justify a therapeutic trial in a second phase, and what the inclusion and exclusion criteria for such a trial should be. A similar two-step approach was recently recommended toward the use of anti-retroviral drugs in chronic fatigue syndrome, a situation similar to that of MS, with urgent calls for treatment from affected patients. Columbia s Center for Infection and Immunity director, Dr. Ian Lipkin, was quoted as saying that (although) we need to address treatment as rapidly as we can, the first order of business is to determine if the association (between the retrovirus XMRV and chronic fatigue) is real. In the case of MS, Canada s Minister of Health and her provincial and territorial counterparts (although two of them have since switched gears) have approved the scientifically-driven, prudent approach being taken and said that they would support a therapeutic trial if and when the initial research shows cause. This is a principled policy decision based on data, despite possibly unprecedented public pressure. It underscores the importance of the research process for informing practice. It would be irresponsible to subject patients to the risks involved in a clinical trial without evidence of the problem and the effectiveness of the proposed solution. As researchers, it is our responsibility to provide the data on which to base evidence-based practice; as physicians, it is our duty to inform our patients of the current state of the science and of the dangers of resorting to medical tourism. 15

17 Un message des IRSC Alain Beaudet, Président, Instituts de recherche en santé du Canada Le D r Alain Beaudet, M.D., Ph.D., est le président des Instituts de recherche en santé du Canada (IRSC). À ce titre, le D r Beaudet assume les fonctions de président du conseil d administration et de premier dirigeant responsable des IRSC. Avant d entrer en fonction aux IRSC en juillet 2008, le D r Beaudet occupait le poste de président-directeur général du Fonds de la recherche en santé du Québec (FRSQ) depuis «Les données sont la source où je m abreuve», m a récemment confié un médecin-chercheur. En effet, la médecine factuelle repose sur des données solides et reproductibles. Cependant, même si nous nous plaisons à croire que notre système de santé repose sur l acquisition et l application de données probantes, l empirisme conserve un grand pouvoir de séduction. Prenons par exemple l article intitulé «Quelles maladies peut-on traiter par l homéopathie», publié dans le numéro du 17 novembre de L actualité médicale, journal largement diffusé dans la profession médicale au Québec. On y recommande des produits comme Aconitum, Arsenicum Alba ou Camphora pour traiter diverses maladies, même si cette approche s est révélée entièrement inefficace dans toutes les études randomisées à double insu où la vérification a été faite. Une exception notable fut l article controversé de la revue Nature sur la «mémoire de l eau», lequel a été retiré plus tard, ce qui n est pas surprenant, car toute action thérapeutique des solutions utilisées aurait forcé une révision du nombre d Avogadro! Plus sérieusement, il faut s inquiéter de l empressement de certains médecins à appuyer le récent «traitement de libération» proposé par le médecin italien Paolo Zamboni, pour la sclérose en plaques (SP). Il est aussi décevant de constater la réaction timide de nombreuses associations professionnelles à cette remise en question de la pratique fondée sur des données probantes (l AFMC et l Association médicale canadienne étant deux exceptions notables). Il est vrai que certaines données corroborent les prétentions du Dr Zamboni, mais ces données ne sont ni solides, ni reproductibles. Pourtant, la demande pour ce traitement a explosé dès que le public en a connu l existence. Cela place les médecins dans une situation difficile, face à des patients qui demandent un traitement dont la valeur n est pas démontrée. Et dans ce cas, les données probantes ne sont pas faciles à trouver; nous ne savons même pas comment diagnostiquer de façon sûre «l insuffisance veineuse céphalorachidienne», qui est prétendument à la source du problème. Néanmoins, le processus de recherche suit son cours normal. Les sociétés canadienne et américaine de la SP ont financé des études cliniques sur le lien potentiel entre la sténose des veines du cou et la SP. Un comité d experts surveille cette recherche pour déterminer si les résultats justifient un essai thérapeutique de phase II et, le cas échéant, quels devraient être les critères d inclusion et d exclusion d un tel essai. Une approche similaire en deux étapes a dernièrement été recommandée pour les antirétroviraux utilisés dans le traitement du syndrome de fatigue chronique. Comme dans le cas de la SP, les patients touchés réclament un traitement d urgence. Le directeur du Center for Infection and Immunity de l Université Columbia, le Dr Ian Lipkin, a déclaré que «nous devons offrir le traitement aussi rapidement que possible, mais notre priorité est de déterminer s il existe un lien réel [entre le rétrovirus XMRV et la fatigue chronique]». Dans le cas de la SP, la ministre fédérale de la Santé et ses homologues provinciaux et territoriaux ont appuyé l approche scientifique prudente qui est préconisée (même si deux d entre eux ont depuis changé d attitude), en déclarant qu ils soutiendraient un essai thérapeutique seulement si les études préliminaires en démontraient l utilité. Il s agit d une décision de principe fondée sur les données disponibles, qui va à l encontre de pressions publiques énormes. Cela démontre l importance d éclairer les pratiques par la recherche. Il serait irresponsable de soumettre des patients aux risques d un essai clinique sans données concrètes sur le problème et l efficacité de la solution proposée. En tant que chercheurs, nous avons la responsabilité de fournir les données probantes sur lesquelles se fondent les pratiques. En tant que médecins, nous avons le devoir d informer nos patients des progrès de la science et du danger de recourir au tourisme médical. 16

18 Return of Individual Research Results: Why the fuss? Bartha Maria Knoppers, Director of the Centre of Genomics and Policy, Faculty of Medicine, Department of Human Genetics, McGill University Bartha Maria Knoppers, PhD, holds the Canada Research Chair in Law and Medicine. She is Director of the Centre of Genomics and Policy, Faculty of Medicine, Department of Human Genetics, McGill University. She held the Chair d excellence Pierre Fermat and was named Distinguished Visiting Scientist (Netherlands Genomics Initiative). A graduate of McMaster University (B.A.), University of Alberta (M.A.), McGill University (LL.B., B.C.L.), Cambridge University, U.K., (D.L.S.), Sorbonne Paris I) (Phd.), she was admitted to the Bar of Québec in 1985 and named Governor and Advocatus Emeritus in Professor Knoppers was the Chair of the International Ethics committee of the Human Genome Organization (HUGO),and a member of the International Bioethics Committee of UNESCO which drafted the Universal Declaration on the Human Genome and Human Rights. Co-Founder of the International Institute of Research in Ethics and Biomedicine (IIREB) ( ), she also founded the international Population Project in Genomics (P3G) and CARTaGENE, a Quebec, population study in From , she served on the Board of Genome Canada, became Chair of the Ethics Working Party of the International Stem Cell Forum, Co-Chair of the Sampling/ ELSI Committee of the 1000 Genomes Project and a member of the Scientific Steering Committee of the International Cancer Genome Consortium (ICGC). Professor Knoppers has received four Doctorates Honoris Causa, is Fellow of the American Association for the Advancement of Science, of Hastings Center (Bioethics) and the Canadian Academy of Health Sciences (CAHS). She is an Officer of the Order of Canada. Patients have long expected their physicians to provide them with the results of medical tests, as have research participants involved in clinical trials where interventions such as drugs or devices are involved. same cannot be said for those altruistic research participants contributing information and samples for fundamental research, such as that involving longitudinal population biobanks. In this era of data-intensive science where whole populations are not only genotyped, but heavily phenotyped, the debate now focuses on the return of research results. Research itself has always been understood as the search for generalizable knowledge and not concerned with the individual, but today the ability to perform whole-genome sequencing at a fraction of what it used to cost is about to change the no returns policy. Moreover, the concept of incidental findings (ie. unforeseen and unrelated to the disease under study) may also become obsolete as the whole genome of a person is exposed, irrespective of the nature of the research. This raises the issues of which results should be returned, when, by whom, and, to whom (if at all). Traditionally, aggregate data has always been communicated via publication in peer-reviewed journals. More recently, websites and bulletins as well as lay summaries of research are made available to participants. Researchers are also urged to return enriched data to research infrastructures, such as population biobanks that serve as resources for disease-specific studies. When citizens contribute samples and data to biobanks they may, however, receive some initial measurements. se do not constitute individual research results. Which Results and When? sine qua non of research is the quest for scientific validity and then, especially in the biomedical field, for clinical utility. We stand at a moment in history when this classical duo needs to be reaffirmed before we risk contributing to the therapeutic misconception that fundamental research will offer personal benefit via the return of individual results. Already, direct-to-consumer internet genetic testing companies are marketing largely indecipherable genetic risk results to clients. General practitioners, confronted by their patients with print-outs on genetic susceptibility, are no better prepared than consumers to deal with what is exposed by whole genome sequencing and what it means. difference today is not that there are research results, but rather the quantity of incidental findings that may also meet the classical duo test. This is where in addition to scientific validity and clinical utility, adding the criterion: an existing therapeutic intervention or prevention exists, may serve to delimit the future, open-ended scope of professional responsibilities. Indeed, the application of this trio is essential to avoiding confusion and misconceptions, to say nothing of potential professional liability arising from the sheer volume of information. 17

19 L AFMC souhaite la bienvenue au nouveau doyen de la Faculté de médecine de l Université de Montréal Raymond Lalande occupera, à compter du 1 er décembre 2010, le poste d administrateur exerçant les fonctions de doyen à la Faculté de médecine. Il succèdera ainsi à Jean L. Rouleau, dont le mandat devait prendre fin le 31 mai Le D r Lalande assumera l intérim au décanat de la Faculté de médecine jusqu à ce que le comité de nomination du prochain titulaire du poste ait mené ses travaux à terme. By Whom? Contrary to clinical trials, genomic/genetic researchers are not necessarily physicians bound by codes of ethics. Biochemists, biostaticians and biologists are probably more involved in fundamental research itself and may not even meet study participants. y are most certainly subject only to contractual or academic obligations to their institutions. Even if the return (or not) of individual research results were to be limited as described previously, and even if this was clearly explained during the consent process, the delegation of such communication to a clinician would still be a necessity. To Whom? In the field of human genetics, families with monogenic diseases are well aware of the risks that hang over their children and biological families. In contrast, genes that contribute to common, multi-factorial conditions provide for the most part only probabilities of risk or resistance. It will be difficult to know who are the family members that may be affected and/or have an interest in knowing or not (especially now with the re-configurations of the modern family). Will the biological family (however defined), become the patient? Obviously, all general practitioners will need to be well-versed in the complexities of human genetics and familial dynamics. Quo vadis? Unless the notion of genetic risk and resistance, the role of the environment and the delineation of corresponding responsibilities are clarified, it is health professionals and researchers who may be the most at-risk. Indeed, the no-returns policy for research results may no longer be acceptable as we continue to tout the allure of personalized medicine. Les doyens sur la Colline 2010 Le mardi 5 octobre 2010, l Association des facultés de médecine du Canada (AFMC) a tenu la deuxième édition de sa journée annuelle de lobbying intitulée «Les doyens sur la Colline» du Parlement. L événement a connu un succès retentissant. Des membres du personnel de l AFMC et des doyens des facultés de médecine de l ensemble du pays ont recontré 50 députés et sénateurs des quatre principaux partis politiques afin de discuter d enjeux d importance nationale. L AFMC s est rendue sur la Colline pour présenter des propositions concernant la planification des ressources humaines du secteur de la santé, une plus grande diversité chez les étudiants en médecine et dans les effectifs de médecins au Canada, le renforcement de la recherche biomédicale et en sciences de la santé et la reconstruction des facultés de médecine en Haïti. Pour en apprendre davantage sur l édition 2010 des Doyens sur la Colline, consultez notre site Web à l adresse suivante : Participants à l édition 2010 de l activité intitulée «Les doyens sur la Colline», de gauche à droite, rangée du haut : Cathy Whiteside, William Albritton, Mark Walton, Steve Slade et Iain Young; rangée du milieu : James Rourke, Philip Baker, Nick Busing et Jacques Bradwejn; rangée du bas : Sarita Verma, Irving Gold, Penny Moody-Corbett et Gavin Stuart. 18