SCIENTISTS  PERSPECTIVE

Dr. MOIRA KAPRAL

Dr. Moira Kapral is a senior scientist at Toronto's University Health Network and an associate professor of medicine at the University of Toronto. Her research interests include cerebrovascular diseases, health services research and women's health. A staff physician in the UHN's Division of General Internal Medicine and Clinical Epidemiology, she also runs an osteoporosis clinic and is a scientist with the Institute for Clinical Evaluative Sciences (ICES).

Until she met Dr. Herbert Ho Ping Kong, in her fourth year of medical school, Dr. Moira Kapral had planned a career as a general practitioner. She became interested in medicine in high school, drawn by a combination of the appeal of altruism and science. Her original vision was to open an office in an under-serviced area of Ontario. Ho Ping Kong was then director of the University of Toronto's internal medicine program, in charge of selecting students admitted to the post-graduate residencies. "He also led Morning Report," a form of highly interactive teaching, she recalls. "We were in awe of him. He made me really excited about internal medicine, his enthusiasm and his way of practising. So I became interested in pursuing that field."

Kapral then did a four-year residency in internal medicine and was named chief resident in her final year. She later completed a master's degree in epidemiology, also at the University of Toronto.

During her chief residency, she worked closely with Ho Ping Kong, attending to both in-hospital patients as well as patients who were part of his private practice. Typically, she says, a patient would come to see him after having seen several doctors who 'were unable to make the diagnosis.

"These patients were essentially languishing in the system," she says. "And he would use his art of medicine to figure out what was wrong, usually by thinking of something that had not been considered before, and do a test to confirm it. It was often a test others might not have wanted to pursue, but he did. And it would lead to a diagnosis and a therapy. That happened dozens of times and the patients were so grateful for finally having an answer." Ho Ping Kong's particular gift, Kapral feels, is the physical examination. "He could use that to find things and not have to rely on other technology."

Beyond his medical skill set, what impressed Kapral about Ho Ping Kong was that, with at least 100 trainee residents under his effective command at any one time, he knew them all on a first-name basis and could engage any one of them on a personal level, asking about spouses or partners or children.

But the art of medicine as modelled by HPK, she says, is at risk, threatened by "an increasing reliance on technology and an over-reliance on formulaic medicine and guidelines." In internal medicine, trainees must demonstrate proficiency in clinical medicine and physical diagnosis. That, she says, is at least partly the result of Ho Ping's Kong's leadership of the Canadian Royal College of Physicians and Surgeons committee on Internal Medicine. The standard tends to be less rigorous in other countries.

Technology, Kapral says, constitutes a mixed blessing for modern medicine. On the one hand, it provides ready access to reams of information that may not be in the knowledge base of the attending doctors. "Nobody has a perfect memory," she says, "and, in the earlier era, if you came up against something you weren't sure about, or hadn't read about, you likely would not have had a quick way of finding out about it, and the patient might have suffered. Now, someone can have access to the most up-to-date information and the latest management plan. On a certain level, care is improved by having that ready technological access to excellent information.

On the other hand, she notes, "Sometimes you may not have access or may go to the wrong source or may not have time to research because things are moving too quickly. If you don't have a certain amount of knowledge, you may not be able to treat people properly in the moment."

Kapral says medical schools across Canada are doing a much better job than they once did of teaching the importance of communication and patient involvement in decision-making, as well as the clinical diagnostic skills needed to practise the art of medicine. "The residents I see coming-through the system have been well trained in management and advocacy. They are by and large committed and caring."

The challenge for medical students to learn the art of medicine has been made more difficult, owing to changes in the training program. In the past, trainees learned it on the wards, seeing patients, having mentors. Today, she says, there is more didactic learning — lectures or research, so the amount of time they are exposed to patients and to role models like Herbert Ho Ping Kong has been reduced. "Fifteen years ago, a resident would feel responsible for the ongoing care of a patient during their stay in hospital, although there was supervision by a staff physician," says Kapral. "Now, spending several half days off the wards, there is less continuity."

Other changes, such as limits on the number of consecutive hours that trainees can work, also have had an impact. On the positive side, the new rules means patients are less likely to encounter a tired, overworked physician. But they also mean a patient's file is more likely to be handed off to doctors less familiar with their case.

The internal medicine specialists that will ultimately succeed the Ho Ping Kong generation have been, she believes, well trained. And they have been strengthened by developments in technology and the rise of evidence-based medicine. Unfortunately, the relatively ease of access to MRIS and CT scans — and the increasing fear of lawsuits — means that sending a patient for an imaging scan has become almost a reflex. Although the per-test cost of such procedures has declined, "the system probably spends more money than it needs to because of the sheer volume."

In any event, she says, such tests will never replace the art of clinical medicine practised at the bedside or the examination room. "You can't know which test to order until you've done a thorough history and physical exam."

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RESPIROLOGIST'S   PERSPECTIVE

Dr. MATTHEW STANBROOK

Dr. Matthew Stanbrook is an assistant professor in the Department of Medicine and the Institute of Health Policy, Management and Evaluation at the University of Toronto; associate editor of the Canadian Medical Association Journal (CMAJ) and a staff respirologist at the Asthma and Airway Centre of the University Health Network.

Born and raised in Toronto, Matthew Stanbrook was always fairly confident he would end up in medicine — in part, he suggests, because his mother was a nurse. But as "the kind of person who always kept my options open," he deliberately spent his first university year studying business, before deciding that the commercial world was not for him. He also briefly considered law, his father's profession. Medicine eventually triumphed and, in preparation, he completed his undergraduate degree at the University of Toronto in pharmacology.

Staying in Toronto for medical school, he expressed an initial interest in trauma surgery. "It seemed glamorous," he explains. But the attraction faded when he was exposed to its harsh realities. "A lot of surgery is tedious and meticulous and careful and that wasn't for me," he says. "I like the process of solving mysteries."

Thus did he end doing his residency in internal medicine, where he specialized in respirology. Apart from the field's many research challenges, Stanbrook had a personal interest —a case of asthma that had plagued him since childhood. The ailment took him to hospital emergency wards on several occasions and, once, he had to be hospitalized for a week.

He found his lectures in evidence-based medicine so fascinating that he  decided to  pursue  a  Ph.D.  in  clinical epidemiology, inspired by public safety physician Ed Etchells md mentored by epidemiological scientist Donald Redelmeier, both at Sunnybrook Hospital. It was Redelmeier who, observing Stanbrook's facility in editing research manuscripts, suggested he get involved in journal editing.

As a result, Stanbrook interrupted his Ph.D. work to spend a year in Boston at the New England Journal of Medicine as its first editorial fellow. Today, Stanbrook devotes half his professional life to his work as deputy editor of the Canadian MedicalAssociation Journal, a position he's held for six years. "It keeps me current on the breadth of medicine," he says, "and gives me a broader perspective on research."

Despite the critical role played by science in medicine, Stanbrook is also a strong advocate of the art of medicine. "Science is what we largely talk about and study and teach and champion," he concedes, "but it's actually only a small part of what we do. The art is everything else that is not science. Some of that art is taught, some is learned by mentorship and experience, some is innate ability. It's usually a combination. But it's more important than science in what we do for patients. It's most of what we do as physicians. Ifyou don't pay attention to it, you will not be a good doctor. And you will know that — and your patients will know it."

Overwhelmingly, he says, medical trainees that fail or are asked to repeat rotations are not faulted for their lack of knowledge. "It's never on the science. It's on the art — failing to be sensitive to the needs of the patient, not listening, not being empathic." Stanbrook says he learned lessons about empathy and breaking bad news to patients in first-year medicine that "are still with me. And I think the earlier you learn them, the more comfortable you will be in the rest of your clinical training."

How does a doctor optimally break bad news:1 With a sense of hope, Stanbrook insists. "You may think, 'Okay, I have to tell a patient he has terminal cancer. There can't be anything I can make a difference with.' Yes, there is. What makes the difference is how that news is received and how it is explained and the opportunity you give them to respond and to ask questions."

The way to begin such conversations, he says, is not "with the conventional, 'Hi, how are you today? How's the family?' but much more directly. cMr. Jones, we have your test results and they indicate you have a lung cancer.' That's what people need to know. There should be no beating about the bush. Address the issue that's on their mind."

When he is delivering such news, Stanbrook then stops. He doesn't hold forth at length on the details. "I want to give the patient time to respond, to let them set the agenda of questions. 'How far has the cancer progressed? What are the treatment options? How long will I live?'"

To the last, challenging question, Stanbrook suggests it's best to be imprecise. "It's okay to give boundaries. But it's foolish to talk about averages, because it's usually variable and it takes away people's hope."

Communicating bad news, he allows, is the most difficult part of his work. It is especially so when patients are younger. "I had a young man in his 30 s, dying of metastatic lung cancer, and he'd done nothing wrong. He'd never smoked. It was just one of these things. So we went from "There's something wrong, let's do some tests and find out what's going on,' to 'It's metastatic cancer,' and then watched him die within a month. That was one of hardest things I've ever had to do."

Everybody has cancerous cells in them, Stanbrook notes, but the body's active surveillance system finds the deviants and eliminates them. In some people, however, the detection system is faulty or goes awry, usually due to genetic variation or environmental exposure. "There's no justice to it," he says. "It's just life and part of my job, and the part you have to be comfortable with, to go into medicine."

Stanbrook views the profound effects of technology on medicine as a double-edged sword. On the one hand, it has conferred enormous benefits of speed and efficiency, access and dissemination of knowledge and simple communication.

Evidence-based medicine itself, the modern paradigm, couldn't exist without technology, he argues. "I don't mean we haven't had science-guided medicine. I'm talking about a culture shift in which we use the research to inform every decision we make. And that's only possible because we now have efficient ways of sifting. All of medical literature is at our fingertips." The development of those archival tools was, he contends, the necessary precursor to the emergence of evidence-based training as the core conceit of medical schools.

In turn, it created a genuine power shift within the medical establishment. Where medicine had previously been shaped by powerful opinion leaders and sometimes-dogmatic voices of experience, now any first-year medical student could challenge conventional wisdom with empiric justification and guide their own learning. "Those experts are still there," Stanbrook notes, "but they have had to adapt. And it's a crisis for them in a way, because science has had to adapt to this environment. It's raised standards, because science has had to take these extra steps to prove efficacy. It's made research more expensive and difficult, but it needed to be that way."

Proving the law of unintended consequences, the great technological leaps of recent decades have also yielded such an explosion of information, that it has become "increasingly hard to keep up" on current thinking in medicine, he adds. The pressure is even more intense because the same technology has given patients unprecedented access to medical knowledge, enabling them to pose more complicated questions to their physicians.

Some three decades ago, one study showed that, in order to keep abreast of new developments in the field, a general internist would have to spend more time reading than there are hours in the day. The situation is much worse now, Stanbrook says, so you have to instruct trainees not to read journals generally, but to read around their specific patients and use those examples to learn.

"We have to manage a great deal more than we used to," Stanbrook says. "And we have to be managers of information more than ever before." The pace of change is so rapid that doctors are constantly playing a game of catch up. "No one yet fully understands the effect of social media. It may be providing opportunities we are missing or causing problems we aren't even aware of."

It was the exponential growth of medical information, Stanbrook suggests, that created the need for sub-specialization. "Gone are the days when a primary care physician can keep up on everything he or she needs to," he says. Does that lead to fragmented care for patients? "It frequently does," he says, "as well as miscommunication and duplication of effort. But if you develop heart disease, a family doctor can do the basics, but it rapidly becomes complicated, and you need a specialist. And having a specialist, study after study shows, makes a difference to patient outcomes."

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