On this episode of the CMAJ Podcast, Dr. Blair Bigham and Dr. Mojola Omole discuss the heated debate over proposed updates to the CanMEDS framework. The controversy ignited when an interim report placed principles of equity, social justice, and anti-racism at the heart of the framework, rather than medical expertise.
Dr. Kannin Osei-Tutu, author of a commentary in CMAJ, proposes a new model for CanMEDS that places shared humanity and compassion at the centre. He argues that the current model of medical education and practice needs to be reimagined, as it has resulted in gross systemic inequities in health outcomes that urgently need to be addressed. He calls for expanding and enriching the concept of medical expertise to incorporate principles of inclusive compassion and social justice.
Dr. Philip Berger agrees on the need for healthcare to be free from bias, discrimination, systemic injustice, and racism but criticizes Dr. Osei-Tutu’s model and the interim CanMEDS revisions for not placing medical expertise at the centre of physician competency. Dr. Berger, a Toronto family physician and member of the Canadian Medical Hall of Fame, is noted for his long history of advocacy on behalf of marginalized groups. He argues that failing to place medical expertise at the centre of CanMEDS is a fatal flaw, as it undermines the credibility of physicians, thereby reducing their influence, which is essential for effective social justice advocacy.
Throughout the discussion, the hosts and guests stress the importance of maintaining civil dialogue and prioritizing the improvement of healthcare outcomes for marginalized populations.
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Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
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X (en français): @JAMC
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Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
On this episode of the CMAJ Podcast, Dr. Blair Bigham and Dr. Mojola Omole discuss the heated debate over proposed updates to the CanMEDS framework. The controversy ignited when an interim report placed principles of equity, social justice, and anti-racism at the heart of the framework, rather than medical expertise.
Dr. Kannin Osei-Tutu, author of a commentary in CMAJ, proposes a new model for CanMEDS that places shared humanity and compassion at the centre. He argues that the current model of medical education and practice needs to be reimagined, as it has resulted in gross systemic inequities in health outcomes that urgently need to be addressed. He calls for expanding and enriching the concept of medical expertise to incorporate principles of inclusive compassion and social justice.
Dr. Philip Berger agrees on the need for healthcare to be free from bias, discrimination, systemic injustice, and racism but criticizes Dr. Osei-Tutu’s model and the interim CanMEDS revisions for not placing medical expertise at the centre of physician competency. Dr. Berger, a Toronto family physician and member of the Canadian Medical Hall of Fame, is noted for his long history of advocacy on behalf of marginalized groups. He argues that failing to place medical expertise at the centre of CanMEDS is a fatal flaw, as it undermines the credibility of physicians, thereby reducing their influence, which is essential for effective social justice advocacy.
Throughout the discussion, the hosts and guests stress the importance of maintaining civil dialogue and prioritizing the improvement of healthcare outcomes for marginalized populations.
For more information from our sponsor, go to medicuspensionplan.com
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
Facebook
Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
Dr. Blair Bigham:
I'm Blair Bigham.
Dr. Mojola Omole:
And I'm Mojola Omole. This is the CMAJ Podcast.
Dr. Blair Bigham:
Jola, we are going to touch on a controversial topic today and the controversy dates back decades, but we have had a re-ignition of it recently, drumming up lots of interest and lots of concern. Let's lay out the situation first. So the Royal College is in the midst of updating the CanMEDS framework. CanMEDS came out in 2005 and was updated in 2015 and people know it as sort of the guiding competencies that describe what a resident should be able to do as they go through training and graduate.
Dr. Mojola Omole:
Medical learner.
Dr. Blair Bigham:
Medical learner, thank you. So this was last updated about 10 years ago and the Royal College wanted to do a refresh of the domains. This is the famous flower petal diagram with scholar, leader, communicator, advocate, collaborator and professional. And at the very middle of all of those flower petals is medical expert. Now, as part of this process, they identified some, what they called, emerging themes, planetary health, anti-oppression, anti-racism, social justice. There were quite a few, and experts drafted some interim reports which were released online last November.
Dr. Mojola Omole:
And I would point out that a big part of what they were trying to do, what they explained was to bring equity and how to actually practice and deliver healthcare in an equitable way to all Canadians.
Dr. Blair Bigham:
And yet one of those interim reports which was focused on equity, social justice and anti-racism drew quite a bit of heat because it placed those principles at the center of the flower petal, replacing medical expertise, and then all hell broke loose.
Dr. Mojola Omole:
It became a very polarizing discussion, mainly in social media and to be quite honest on Twitter, currently known as X. And instead of having that same polarizing conversation, we want to take a very different approach because here on the podcast, Blair and I have always talked about the ending to most of our podcasts is like, well, we just need to improve social determinants of health and things would be better. And so for us, this is something that we both deeply and I would say at the CMAJ really care about is a concept of equity and looking at the role of oppression and racism in determining health outcomes for various populations in Canada.
And I hope that there are a lot of our colleagues who want to have good faith and honest open discussions about this because I do think, and I share with them some concerns with replacing medical expertise at the corner of it. I guess I view it as let's have a nuanced medical expert who understands, for example, our episode on gout, that allopurinol is dangerous for certain Asian populations and could kill them. That is a form of having equity in your healthcare system to understand that.
Dr. Blair Bigham:
Absolutely. So here's our approach today, after about five months after the Twitter storm sparked by that Royal College interim report occurred, a commentary written by our first guest was published in CMAJ. It's entitled, “Redefining excellence in healthcare: uniting inclusive compassion and shared humanity within a transformative physician competency model.” It proposed a new pictogram, replacing the flower petal with four overlapping circles with shared humanity and compassion at the center. We'll speak to the author about his model and how it's different from both the original CanMEDS flower petal and the interim report from Royal College that was released in November.
Dr. Mojola Omole:
And then after that we'll speak to someone who shared his concerns about the proposed visions to the CanMEDS. Dr. Philip Berger wrote an op-ed in the Toronto Star laying out his thoughts and we'll be speaking with him as he's someone who's actually been at the forefront and majority of his family medicine practice has include social justice and social activism in the realm of HIV/AIDS and refugee health.
Dr. Blair Bigham:
Our goal is to lower the temperature on the conversation while still getting to the heart of the matter. That's coming up on the CMAJ podcast. Dr. Kannin Osei-Tutu is the author of the commentary in CMAJ. He's Senior Associate Dean, Health Equity and Systems Transformation at the Cumming School of Medicine at the University of Calgary. Kannin, thank you for joining us today.
Dr. Kannin Osei-Tutu:
Thank you. It's great to be here.
Dr. Blair Bigham:
One of my mentors always used to say, if it ain't broke, don't fix it. What is the central problem that your model for medical education is trying to address?
Dr. Kannin Osei-Tutu:
I like what your mentor once said, I also like to refer to a quote that says every system is perfectly designed to get the outcomes it gets. If we want to change the outcomes, we have to change the system. And we know that in the current context of medical education, I don't think the healthcare system is working for everyone equally, at least not as optimally as it could. And anytime we have an opportunity to reimagine or re-envision a better system, a better way forward, a better way to practice medicine, I think it's an opportunity we should seize and it's within that spirit that I wrote that commentary. So we have evidence that shows, for example, that white trainees have an implicit preference for white individuals and we're more likely to treat white patients and not Black patients with thrombolysis, in the case of MIs.
We have evidence from my home province in Alberta that shows indigenous patients are triaged with lower acuity scores compared to non-Indigenous patients. And their concerns are taken less seriously when they show up to the emergency department. And when treatment is received, it's delayed and when it's received, it's often inferior. And so the question is is this due to a lack of medical expertise or is it due to something else? And so when we have this evidence, why are we not responding to it? What can we do better? The gaps in terms of health outcomes and inequities continues to grow, not narrow, and so we should ask ourselves why that's happening.
Dr. Blair Bigham:
Describe for me how the model that you've proposed is different from the status quo model of education that the 2015 CanMEDS presents.
Dr. Kannin Osei-Tutu:
Yeah, the model I've proposed is, and the paper I've written is meant to be a thought piece in many respects and it's meant to shine light on some things I feel we could have more of in healthcare and some things I feel that may be missing that may explain some of what we're seeing in terms of outcomes. And so the model wants us to center on or focus on or shine a light on inclusive compassion and shared humanity, both of which I think we need more of in healthcare and I think would lead to a better healthcare system. And so bringing that lens more to focus, it's something I think we intuitively think we do as physicians, but when we look at outcomes and how patients actually are treated and what the outcomes are, we see that there's a gap between I think our best intentions and what's actually happening to some patients in this healthcare system.
So the model wants us to pay attention to that and then it provides mechanisms, it seeks to provide the medical expert with tools, mechanisms, lenses or approaches that one could apply in a given situation to help close those gaps. And that's where the foundational pillars and the ethical framework provides those mechanisms that one might need, consider employing in a given situation, which we're not trained about in medical school, how to be anti-racist, what does anti-oppression mean? What does a social justice lens mean to healthcare? How does one be culturally safe? These are things that have become much more apparent, that are important and needed for many of our patients, but there's still a gap between those needs.
What we're taught, and then there's a whole group of us in the middle, I would say those of us now that were out in practice for 10, 15, 20 years that never received this training or education because it wasn't part of our medical school curriculum or our exposure. So we've been practicing, doing the best we can without realizing that we're in a system that is perpetuating harms because it's not intentional in addressing some of these fundamental competencies that are required of the 21st century physician.
Dr. Mojola Omole:
I'll be honest, I'm going to be very blunt. What is shared humanity and inclusive compassion? And not saying that we don't need to have more humanity in medicine and compassion even just for each other as colleagues, but then also for our patients. But how can that be the center of medical education?
Dr. Kannin Osei-Tutu:
I guess I would ask you the question, how can that not be the center of a person providing care to another individual? You don't have compassion and you don't see them as human, how can one provide care?
Dr. Mojola Omole:
Well, my question would be that, not my question, my answer would be that when we do need to see people as humans and we need to have compassion when we take care of our patients, but I guess for me also is that the concept of the CanMEDS as something has to be in the center and something and things are on the outside does not make sense to me. I view things more as a tree and things have to be part of the foundation. For me, you do have to be compassionate and have humanity at forefront when you're a physician, however, you also need to know what to do.
I'm not going to hire a plumber that's nice to fix my plumbing if they don't know how to do basic plumbing. And I also think that the terms of shared humanity and inclusive compassion is nebulous. I know what you mean because I also work in this space, but for most people who've never had to think about their humanity because their humanity has never been questioned, whereas I'm a Black, queer woman and my humanity is often questioned. So if you've never had to think about it, you're like, what the hell is this talking about?
Dr. Kannin Osei-Tutu:
Yeah. So I think you raise a good point about the importance of definitions, and one thing I've attempted to do in this brief commentary, you get a thousand words to try to pack a lot of concepts in there, is provide definitions that people can refer to, reflect on, process. So definitions for those terms are provided within the commentary, but there's also an appendix which has a larger glossary of terms, which I think are very important and instructive to read because this is new language or new concepts that we're introducing or attempting to introduce into the context of physician training for some folks. And I think that people assume they know what is being referred to without actually going back and looking at a specific definition, which I think is really important to do because these provide the building blocks to understand the rest of the conversation.
Dr. Mojola Omole:
So I guess even, and people don't read the appendix, I'm kind of like in that language it is, that is your definition of it, but that's not a known definition of it because to me that actually is still part of medical expertise because what you're saying is that it is important to know that Black mothers and infants have different outcomes because of the fact that they're Black, that is actually medical expertise and not about compassion or humanity.
Dr. Kannin Osei-Tutu:
I agree with you that a false dichotomy has been created in this conversation, not just this conversation, but other conversations that are pitting the notion of medical expertise and these concepts of inclusive compassion, shared humanity, anti-racism, et cetera, as either/or or that they're dichotomous. In this paper, I clearly call for an expansion and an enrichment of medical expertise that incorporates these other concepts and that they're integral to being a medical expert. I think this has to be part and parcel of what it means to be a medical expert. I think people get caught up on, without reading thoroughly through, get fixed on a certain aspect, how something appears in a diagram or where something is located without actually having a conversation about what we're talking about.
And that's what I think is doing a disservice to the profession at this point in time that people get very fixed in a representation of what they think they should be seeing, which takes away from the opportunity of actually having a discussion about what we want to be talking about because my paper clearly calls for an expansion of medical expertise and enrichment, a more nuanced conception of what that would incorporate, these important things that our patients are asking us for. And if our sense of compassion and humanity was enough right now, then why do we have the gaps in healthcare? Why do we have the different outcomes that we see for certain populations if that's already there and we don't have to focus on it more or make it more explicit in terms of our conception of what it means to be a medical expert.
Dr. Blair Bigham:
Kannin, let's talk about the pictorial representations here and how things maybe went off the rails when your proposal came out. The original, or I'll say the 2015 CanMEDS pictogram that I think most people are familiar with, had all these flower petals of attributes that make a good physician and then I think it's called the pistil of the flower, the middle of the flower was medical expert.
Dr. Mojola Omole:
That is the nerdiest thing you've said.
Dr. Blair Bigham:
I Googled it before.
Dr. Mojola Omole:
What is a pistil?
Dr. Blair Bigham:
I actually texted my aunt who's a gardener and was like, am I using the right term? Okay, so anyways, the original pictogram had medical expert in the middle and your pictogram shook that up and medical expert moved to sort of an outer ring and then something happened on social media that you described as a distortion. Just tell us about how your vision was misinterpreted.
Dr. Kannin Osei-Tutu:
So my vision is for us as a profession to shine a greater light on inclusive compassion and shared humanity because I feel that more of it in healthcare would be of benefit. In order to do that, we need to make room for us to conceive and to think about that and reflect upon it. I write explicitly that medical expertise is expanded and enriched to incorporate these other important elements. I'm not a graphic designer. You do the best with what you can. I had some assistance with creating the model and putting things in a way that made sense to me and that was the representation that made sense to me along with the supporting text and the rest of the things that accompany the paper, which answer and speak to some of the distortions that were created on social media. So it's easy for people to look at one thing and oh my goodness, it's sacrilegious.
Something's moved and changed out of place and the sky is falling. That's one response. Or we could engage in the conversation and speak about why this is considered important, why we want to enrich and enhance, why this needs to be a nuanced conversation. But I think that's very threatening to people when we're talking about new ideas and new concepts. What I've presented is a model and there hasn't been a new model presented since the original CanMEDS in 2005, so it's going to cause a reaction, but this is my opinion, my thoughts. I don't speak for the Royal College, I don't speak for CanMEDS, I don't speak for any organization or institution. I'm an associate professor. These are thoughts that I felt was a way to represent what I felt was important and meaningful from my perspective.
And I invite other perspectives and hope others will put out other models that improve mine, challenge mine, improve the current status quo version. But clearly something has to change because the status quo is getting us the outcomes that we currently experience. And as I said before, every system is perfectly designed to get the outcomes that it gets, and so if we understand that the system isn't working well for everybody and we have the tools and mechanisms to improve it, some of which I proposed in this framework, everything else that exists in CanMEDS still exists in this current framework. Nothing's been taken away. I've only added more to what could be a vision of a better future for healthcare.
Dr. Blair Bigham:
Since all of this discourse began after you've released your diagram and your paper, have you had any regret? Would you change the diagram at all now that you've had all of this discourse go on sparked by its release?
Dr. Kannin Osei-Tutu:
Well, this was a thought piece and a way to introduce some new concepts into the conversation, and I presented a model in transformation and also an evolution. And if I was to do a next version of the model, I would reposition medical expert in the center and more clearly speak about the incorporation of the social determinants of health to be embedded within that expertise so that we have an expanded and enriched concept of what it means to be a medical expert, but that those social determinants of health and the mechanisms to address them do need to have prominence so that they're not forgotten about or overlooked. So if someone was to take my model and put out an alternative that better met the needs from their vantage point, I would welcome that.
What I'm really hoping we can have as a profession is space to have this dialogue and to have that opportunity to exchange ideas with the idea of ultimately making things better for our patients, better patient outcomes, and finding ways in which we can do that because the current framework obviously needs some improvements in that regard and what it ends up looking at the end of the day, who knows. My input is one input of about 8,000 or more that have come from a variety of different sources and many, many more sources will come, but I hope this serves as a place where people can go and look, read, reflect, think about things a bit differently, get familiar with some of the terminology, and have at least a bit of a visual representation as to how things could potentially be put together and propose something better.
Dr. Blair Bigham:
Thank you.
Dr. Blair Bigham:
Dr. Kannin Osei-Tutu is the Senior Associate Dean, Health Equity and Systems Transformation at the Cumming School of Medicine at the University of Calgary.
Dr. Mojola Omole:
It's safe to say that the proposed revisions to CanMEDS has been controversial. Dr. Philip Berger wrote an op-ed in the Toronto Star recently challenging the central tenets of the proposal. Dr. Berger is a long-term family physician in Toronto affiliated with St. Michael's Hospital, and he's a member of the Canadian Medical Hall of Fame. He has been at the forefront of many battles for humane healthcare for refugees, members of the LGBT community, people with HIV and other marginalized groups for which he was decorated as an Officer of the Order of Canada. Philip, thank you so much for joining us today.
Dr. Philip Berger:
Thank you for having me.
Dr. Mojola Omole:
So let's just start off. What was your reaction initially to the proposed changes to CanMED and then the commentary by Dr. Osei-Tutu?
Dr. Philip Berger:
Well, it may surprise you that my initial reaction was in agreement with a lot of what Dr. Osei-Tutu wrote, describing the characteristics and competency of doctors. For example, healthcare practice is free from all forms of bias, discrimination, systemic injustice or racism, it's impossible not to agree with that. So I'm glad he's raised that and others I know are grateful that he's raised the systemic prejudices that make people sick and impede their recovery and his analysis is quite well articulated and written. I was very impressed, but nonetheless, to me, the proposal has a number of serious flaws, particularly in regard to the role of physician as medical expert.
Dr. Mojola Omole:
Can you elaborate on what gave you pause from your perspective as someone who is viewed as a social justice activist in the realm of medicine?
Dr. Philip Berger:
Well, Dr. Osei-Tutu writes, and I agree with him, that medical expertise is the, quote, cornerstone of the profession. Yet, in his text and on the diagrammatic representation of the transformation of the competency model, it's at the fringes, at the margins. Medical expertise, if it is an authentic cornerstone, is foundation to all physician roles, including the social justice activist or advocate. That's a cornerstone means, foundational. Medical expertise is exactly what gives doctors their standing, their power and their influence with the public government and institutions like hospitals and universities. You minimize medical expertise, you minimize their credibility, remove medical expertise as a bona fide cornerstone. In my view, the entire enterprise of clinical medicine and activism collapses. That's my major objective, because I think it's actually a fatal flaw in his proposal.
Dr. Mojola Omole:
What led you to incorporate social justice work, whether it was with refugee, humane refugee health or HIV/AIDS patients, what led you to incorporate that into your work?
Dr. Philip Berger:
Well, there was one instance in the late-1970s where I did a house call on a man in South Riverdale, Toronto. He lived in a room of a rooming house and he was a World War II vet who had prostate cancer and he let his OHIP coverage in Ontario lapse and he was being sent notices from collection agencies, which completely terrified him and wrecked his life. I could still see his face in my mind, and I have to tell you, as a young brash, sometimes not-so-polite physician, I became fairly enraged and wrote very heavy letters, I'm not going to name the hospital, to the teaching hospital in Toronto that hires this collection agency.
That was really the first instance that I can think of that may have led me to act, and I can't say it would've because every individual I saw came with a story and came with their social circumstances, their family background, whether it was refugees from South America, people with HIV/AIDS, and I have to tell you that medical expertise was always a cornerstone for me, and it really is of every physician activist that I know of, whether it's in their struggle with others for social justice, and I say others because these issues of inequality are inseparable from goes on in the rest of society and Canada or whether it was in upstream interventions.
Every single physician I know relied on their medical expertise and in fact has now transformed into medical organizations that rely on their medical expertise, whether it's the Canadian Association of Physicians for the Environment, the Canadian Doctors for Protection from Guns, which I'm a member, or Doctors for Decriminalization, the clout of those organizations rests solely in the fact that they're medical expert. From there flows social activism, fight for injustice, fight for fairness.
Dr. Blair Bigham:
In your Toronto Star, op-ed, you wrote, I don't think it's the business of medical faculties to be teaching and evaluating political philosophies in the context of a curriculum, and I'm trying to balance that with your Order of Canada citation, which reads that your efforts have helped change medical policies and your mentorship has inspired physicians in their own journeys. How do we go about blending both that medical expertise that is foundational, but also, what is the role of medical schools in teaching or inspiring acts of advocacy or activism amongst physicians? How do you reconcile those two things?
Dr. Philip Berger:
First of all, I'm not responsible for the Order of Canada citation. I should put that right on the record.
Dr. Mojola Omole:
But it's about your work and how you lived it.
Dr. Philip Berger:
I lived it, but it's someone else's description of my work, of course. Concepts like social justice and intersectionality or anti-oppression are viewed by some of my colleagues as ideologically based. I do not necessarily agree with them to tell you the truth, but these colleagues have said to me and asked, how do doctors decide who's an oppressor and who is a victim, which doctors decide? And the answer in my opinion will vary wildly according to the worldview, the political philosophy or even the doctor's religious beliefs. To rely on one worldview to the exclusion of others, especially in medical education, they feel is unfair and discriminatory.
I should add that in my opinion, nobody has a monopoly on the truth. And learners who are in an imbalanced relationship with their teachers or supervisors as they are, may feel impelled to cough back, regurgitate opinions with which they might disagree. So even if I did agree with that view, which I don't necessarily, it does not mean that advocacy techniques and tactics cannot be taught irrespective of the student's personal beliefs and values, whether you're right-wing or left-wing, a student or a faculty could apply many of the actions that I've done in my life.
Dr. Mojola Omole:
I just wanted to follow up with that. For me, the word social justice is not something, I don't use it on a daily basis, and I do find some of those terms to be very nebulous. However, as a Black woman who not so recently but recently enough remembers the scare I had to have a baby because I know the maternal outcomes for Black mothers and their babies, I was scared out of my mind, and there's data to show that. So I guess to me, it's like when people are saying, well, this is a worldview of a, who's the oppressor, who's the victim? We have data that shows in healthcare that certain groups have poor outcomes. It is factual. So that tells us, I don't even think it's to name that someone is an oppressor, but it's to say, well, this is the outcomes for certain people. We need to reverse that.
Dr. Philip Berger:
I completely agree, and I knew this from my work in HIV/AIDS, it was known back in the, almost 30 years ago that African-American women had much poorer outcomes if they had HIV infection, and you probably know this better than I do. There are many studies and data that show that. I think those outcomes are inseparable from the systemic biases and racism and unfairness that throughout all sectors of society and permeate directly into the healthcare system resulting in those poorer incomes. To me, the question is what do we expect physicians to do about it? What obligation do they have? I'm not sure if you asked the public, and I think the public should be asked in some way, and I'm not saying this is a way of getting away from responsibility to make decisions on competency, but if you ask the public, do they want their money, taxes that they're paying through medical education to go primarily to creating a, quote, critical mass of physicians to affect social justice change or to produce competent doctors, I think they would offer the latter.
It doesn't mean they're mutually exclusive, but at the very base of the foundation, there has to be medical expertise. I also think that, and I agree with Dr. Osei-Tutu, we talked about kindness and compassion and empathy, and I'm glad he did, 'cause I agree those should be the center of his four concentric circles, but I think that can be taught or modeled. You can't enforce it. I know some doctors are absolutely incapable of kindness and empathy, and we probably all do.
But when patients are given a choice of a hand-holding doctor who's mediocre in their skill in the view of their referring family doctor or exceptionally skilled doctor who's impatient and brusque, and I've had one of those myself, by the way, I think they will mostly, or if not always choose the latter. That doesn't mean doctors are excused from the responsibility of examining their own biases and how that would impact patient healthcare, but I don't think it can be prescribed or enforced. I don't think it's the role necessarily to create a critical mass. Hopefully that would happen naturally by students seeing how their doctors are intervening on behalf of patients and communities.
Dr. Mojola Omole:
I would say though that it hasn't happened so far. I was part of the first round of CanMEDS. I graduated med school in 2007. And I struggled because it's that you have done this, and I get what you're saying that not all doctors have the ability to have compassion, but to me it's not even about compassion. It's about understanding that there are differences in health outcomes. It's like some patients can't afford the fancy asthma inhaler, so don't prescribe that one, because we did a podcast on the different asthma inhalers and how one's easier to use, but it's more expensive and all of those things. To me, understanding social determinants of health is what makes you a good doctor. You still could be brisk and not the warmest person, but if you don't understand the social determinants of health, I personally don't think you're a medical expert.
Dr. Philip Berger:
I agree completely.
Dr. Mojola Omole:
But then how do we create, I guess you're saying that it's not important because my goal is that you have inspired many people, but you are not everywhere in family medicine. How do we have people like you who modeled this across the country, how do we end up having little mini Dr. Bergers everywhere?
Dr. Philip Berger:
That may not be viewed favourably by a lot of people, by the way, but anyway...
Dr. Mojola Omole:
But I think it would be viewed favourable by your patients.
Dr. Philip Berger:
No, I think the answer, and I said it earlier, is to look at the patient through their own eyes, not the doctor's eyes. To me, the best professors I ever had were actually sick people, not university faculty, and of course, social determinants should be taught. The data you referred to early should be taught. The effective systemic bias and discrimination should all be taught. People ought to know that newcomers got Covid at much higher rates than anybody else did. That poor communities got hit with Covid much harder, and the vaccination rates were lower until there was actually an intervention by the state and the profession. Of course, it should be taught that, but I don't know if you can tell someone, you must become a social activist and lobby as I did for higher welfare rates. I mean, it's sort of a bit peculiar to me to try to put activism in the academy.
It's like medicalizing all problems. I mean, these are street problems. These are the public's issues. Doctors are part of the public, and if they're responsible citizens, I'll participate. The benefit they have over other citizens, I'm being repetitive, I apologize, is their medical expertise. It gives them all sorts of power that ordinary people do not have, and they're listened to. I've seen it, personally, in 1981, I gave a presentation to the Ontario Legislature Standing Committee and Justice about police brutality, and the vast majority of people who I documented were racialized people or newcomers. Well, an ordinary citizen could have gone and complained about it, but they listened to me, hit the front page of The Globe and Mail actually. I showed them photographs. That to me is a classic example of a doctor intervening, but I don't think I could compel my colleagues to do it. In fact, I had three colleagues who helped me, who did not want to be identified publicly with this type of action, that was over 40 years ago. They were afraid of the police.
Dr. Blair Bigham:
Over your experience, you have inspired a lot of people to take action, if not in curriculum, how else could we address the troubling inequalities in health outcomes for so many marginalized groups? How might you coach or inspire others to take up the charge if not formally in a curriculum?
Dr. Philip Berger:
Well, social determinants of health should be taught in the curriculum. It should be mandatory, and it should be expansive to different sectors that we all know have been penalized by the unfairness and inequalities. I think that has to be, I guess my main point is you start with medical expertise and go immediately to social justice or anti-oppression or anti-racism, not the reverse. And the effect doctors has, and again, I'm being repetitive, I apologize, is because of the medical expertise.
Dr. Mojola Omole:
I'm wondering if, no, I guess I was just thinking, let's say we were to, let's say we were the working group to revision the CanMEDS, the little flower petal, first, I think I would use more of a tree, but I wonder if it's the fact that we're all speaking the same thing. We all want the same outcome. Maybe it's to expand putting the social determinants of health as a core competency of medical expertise.
Dr. Philip Berger:
Well, you could, I mean, I think that should be a mandated part of the curriculum. I think there is a remedy to Dr. Osei-Tutu's proposal, and that's to put medical expertise in the center with shared humanity and inclusive compassion. Then I wouldn't have many complaints to be quite frank. It would lead immediately, graphically, pictorially to anti-oppression, anti-racism, social justice in the second concentric circle. Then the integrity of his proposal would be preserved.
Dr. Mojola Omole:
Thank you so much.
Dr. Blair Bigham:
Thank you.
Dr. Mojola Omole:
Dr. Philip Berger is a family physician in Toronto, and he's a member of the Canadian Medical Hall of Fame. Thank you so much for joining us.
Dr. Blair Bigham:
All right, Jola. So you and I are both trained journalists and at this point in our lives, we know that when there's two sides to a story, it's usually because the story is complicated, right? There's issues that are complex, three sides, four sides, five sides. But I've come to learn through my journalism career that both sides usually hold part of the solution. And so not that we're going to hedge here, but things really fell off the rails on social media and in the popular press with warring op-eds. But it sounds to me like Kannin and Philip are on the same page for the most part. What's your take?
Dr. Mojola Omole:
Yeah, I think we're all on the same take. I think that, I know that both of them are thinking about marginalized groups and how to improve the healthcare of them. And after speaking to Kannin was that there's not, they're not trying to diminish medical expertise, but it almost feels as if they feel like there's not enough space in the middle to put something. It should be medical, I personally think it should be medical expertise encompassing the social determinants of health.
Dr. Blair Bigham:
Yeah, and I agree. I don't think we need to read between the lines here. Kannin wrote it plainly. Maybe not so much visibly in his pictograms.
Dr. Mojola Omole:
Okay, but here's the problem with that. I'm going to fight you back on that. The picture means a lot.
Dr. Blair Bigham:
Oh, sure, but hang on, here's what he said. I'm going to quote him, hang on.
Dr. Mojola Omole:
Blair, we're going to fight about this.
Dr. Blair Bigham:
We can fight about it. But he wrote this demands that a physician's responsibilities extend beyond medical expertise, but then he says, which is the cornerstone of the profession as it should be to encompass principles of inclusive compassion and social justice. So he wrote what everybody is talking about. It just didn't come across in the pictogram. So I got to say, it seems like semantics.
Dr. Mojola Omole:
No, it's not semantics though, because as the youth say, TL;DR, like that is what the picture is. I hope to God I got extra bonus points for that. But the picture, we cannot de-emphasize the fact that we are still toddlers. What the picture shows matters, and when you take it out of the center of the picture, you are devaluing it, even though the text doesn't say that and the text still elevates it, the original text though, from the CanMEDS was, rather than.
Dr. Blair Bigham:
Well, that was in an interim draft proposal, and you're right, it did say that social justice rather than medical expertise should be at the center.
Dr. Mojola Omole:
In the business of medicine...
Dr. Blair Bigham:
Which is not what Kannin wrote.
Dr. Mojola Omole:
But in the business of medicine, there's no interim. These are people's lives and patients that matters to them, to the public, and I would say with, and I push back with Kannin regarding that is that, the picture does matter. You can't say or read the text because you need to update that this has to include that we know, I'm a surgeon, so the concept of shared humanity and compassion is inclusive compassion is challenging for me to hear.
Dr. Blair Bigham:
I thought you were going to say you like picture books.
Dr. Mojola Omole:
I do like picture books, but I mean, I think it's really hard for me, and even though I hope my patients feel that I'm a very empathetic and compassionate physician, I do think that that is hard because everyone's definition of compassion is different. Social justice is also different. And so when we have terms like that in this picture, even in the text, that's problematic because it's left up to interpretation.
Dr. Blair Bigham:
And a lot of these aren't newer principles, newer philosophies, newer terms, and not that we need a glossary here, but there are differences in how people understand some of the language that's been thrown around here. But look, here's my bottom line on it. Forget about the pictogram. Forget about what's in the center of it all. What's happened here is that we know that every house has a foundation, but my house looks different from your house, looks different from Neil's house. The foundation is solid. It seems like everyone agrees, medical expertise is the foundation, but for the house to be functional, for the house to be livable, for the house to be beautiful, that's where all this context and nuance comes in. And we've lost that in the debate because it somehow got polarized to, do doctors need to know anything about medicine?
Dr. Mojola Omole:
And I completely agree.
Dr. Blair Bigham:
It's a lost opportunity.
Dr. Mojola Omole:
I don't think, I don't feel that the conversation that's been in social media or even in media actually reflects the conversation that we've just had with two people who deeply, deeply and have personal experiences with improving health inequities. So my take away from this is, please don't go on Twitter to have fights with people. It's never productive. Also, and we need to figure out a way for us to have civil conversations with each other, respecting that each of us have opinions that matter, and that at the core of all of us is to use Kannin's word, a shared humanity.
Dr. Blair Bigham:
Within that shared humanity. We do need to recognize that for some of us, there's an urgency, a priority to addressing some of these inequalities. And I think that's where the passion comes out, because I go to the ER, I go to the ICU, everybody there is there because of an inequality it seems most days. So there is an urgency to this. This is crumbling the healthcare system. This is why society isn't where it could be. And so being able to advance these conversations without the polarization, without debating false narratives and stupid dichotomies, it's just a call for us to come together and really ask ourselves, how do we create better doctors? And I do still believe that the Royal College has a role to play in how we do that, and that curriculum is so important. I just hope that that conversation can get back on track because we need to advance our medical education so that we are better prepared to fix these glaring discrepancies in who lives and who dies.
Dr. Mojola Omole:
That's it for this episode of the CMAJ Podcast. If you like what you heard, please give us a five star rating wherever you get your podcasts. Share it with your networks and leave a comment. This is actually an important topic for us to have and create dialogue around. The CMAJ Podcast is produced by our phenomenal producer at PodCraft Productions for the CMAJ. Thank you so much for listening. I'm Mojola Omole.
Dr. Blair Bigham:
And I'm Blair Bigham. Until next time, be well.
Dr. Mojola Omole:
And please chill out on Twitter. Let's not fight. All we need is love. All we need is love.