The Choice—Excellence or Mediocrity in Health Care

MR. GORE:

It is my sad duty to inform you that on Tuesday, October 25, our oldest living Past-President, Mr. Herbert Gordon Stapells, Q.c., passed away.

Mr. Stapells was President of the Empire Club of Canada during the year 1931. He achieved a great degree of eminence in his profession as lawyer in the field of taxation. He retired from the practice of law ten years ago and since retirement spent much of his time in Bermuda, where he was special tax consultant to the Bermuda government. He found the climate on that island beneficial to his health.

He was a very generous man. His generosity and desire to assist people caused him to establish the Stapells Eye Foundation at the University of Toronto in 1959. This foundation sponsored research in eye diseases. His greatest contribution was his support of young people entering this field of research but in the early days of the programme he also provided special equipment. Mr. Stapells made a great personal contribution to this foundation. He served on the Board of Trustees of Wycliffe College since 1931 and has been interested in assisting young clergymen.

Mr. Stapells had a number of brothers and sisters. An older brother, Mr. R. A. Stapells, was President of this Club in 1919. His son, Bredin, is our President. It is with great assurance that I express your thoughts when I say that we send to Bredin and all the members of his family our deepest sympathy.

As a token of our sympathy and in memory of our friend and Past-President, I ask you to rise and observe a moment of silence.

We may tend to think of the medical research scientist as one who is cloistered in his laboratory, content to let practising physicians deal with patients. This tendency may be re-inforced by the knowledge that this is an age of specialization, to which the medical profession is as subject as other professions.

I find it interesting, then, that our guest today has demonstrated that the interests of a medical researcher can reach out from the laboratory to the patient.

One of Dr. Mustard's interests is in the mechanism of the formation of blood clots in the living cell. This has involved him in the investigation of the relationship of diet to heart disease. His close association with the Department of Medicine, and through this with the teaching hospitals of the University of Toronto, has enabled him to keep in the mainstream of medical practice and to investigate the nature of Blood cells in patients with heart conditions.

His broadly-based approach to research led to the formation of the Bureau of Research Volunteers of the Ontario Heart Foundation and one of the projects involving volun teers co-directed by Dr. Mustard is concerned with diet control.

It is clear, then, that our guest can speak of medical research with first-hand knowledge of not only its requirements in terms of staff, equipment and finances but of the practical problems in applying the benefits of research to the patient and of the diverse routes along which such applications can proceed.

The establishment of the Medical Research Council by the federal government, thus giving to this field a priority and status which it did not enjoy previously, made many of us aware of the urgent need of the medical profession in Canada for increased support for research. The Gundy Report also increased public awareness and interest. We have read of the extent to which medical research in Canada was supported by funds from both government and private sources in United States, and the repercussions of a cutback in this source of support. Recently our medical friends have suffered another "shock" in the suggestion by the Minister of Finance that the government, as part of its belt-tightening programme, may have to reduce the increased funds which were voted at the time the Medical Research Council was formed. Possibly we will hear some comment on the implications of these developments today.

Our guest was born in Toronto in 1927, and attended Whitney Public School and the University of Toronto Schools, winning the Nesbitt Silver Medal on graduation in 1946. On graduation, with honours, from the University of Toronto Medical School in 1953, he was awarded the Cody Silver Medal, the Roy Simpson Scholarship in Pediatrics and the Chapel Prize in Clinical Medicine.

His junior internship at Toronto General Hospital was followed by two years of postgraduate study at the Department of Medicine, Cambridge University, where he earned his Ph.D.

On his return to Canada, he was a senior intern at Sunnybrook Hospital and then a senior research associate with the Department of Veterans Affairs and a fellow in the Department of Medicine, University of Toronto, in the succeeding few years.

In 1958, Dr. Mustard was awarded the Medal of the Royal College of Physicians of Canada for an essay entitled, "A Study of the Relationship Between Lipids, Blood Coagulation and Atherosclerosis." This is a national competition and the winning of this medal is a great tribute to the recipient.

Dr. Mustard is consultant to the Department of Physiological Sciences, Ontario Veterinary College, Guelph, another example of the diversity of his interests.

He was a research associate with the National Heart Foundation of Canada, 1960-61, and in the two years following a research associate with the Department of Medi cine, University of Toronto and a senior research associate with the Canadian Heart Foundation. In 1963 he was named as a research associate of the Medical Research Council. He has been associated with the Blood and Vascular Disease Unit of the University of Toronto. He became a Fellow of the Royal College of Physicians and Surgeons of Canada in 1965.

His interest in teaching, which led to an appointment as assistant professor in the department of Pathology, University of Toronto, has taken him to a new post and to a new city-he is now Professor of Pathology at McMaster University in Hamilton where he has the opportunity of helping to establish a new medical school.

From this rich and varied experience on the front lines of medical research, it gives me the greatest pleasure to introduce to you, Dr. J. Fraser Mustard, F.R.C.P.

DR. MUSTARD:

I must first of all say that it is a pleasure to be invited to address the Empire Club. The food has been good and my companions at lunch have been entertaining.

I only wish that I was more certain that my comments will be as entertaining. In order to provide a background for my remarks, I would like to give you two quotations. The first of which is as follows-"Tomorrow grows out of today; and the aspirations and activities of the present determine the channels along which all of the energies of the future are to flow forth. The times we live in are big with opportunity". This is from an address to the Empire Club on January 18th, 1906 by the Rev. Dr. E. D. McLaren, General Secretary of the Presbyterian Church of Canada.

The second quotation is from an article by Jerome Weisner when he was Dean of Sciences at the Massachusetts Institute of Technology. "I believe that the present emphasis on formal learning in the Colleges and Universities and the almost complete lack of contact with real research in the undergraduate years can be very harmful." He was referring in particular to University education in the Sciences. These quotations illustrate the two main points I will consider. The opportunity which we as Canadians have in developing our Health Care Programme and the importance of research in Education in the Sciences. Today I wish to discuss with you the problem of Health Care, Medical Education and Medical Research. Although I will concentrate on medicine, what I have to say applies to other areas of scientific endeavour in our society.

The Economic Council of Canada recently stated that research and education are the cornerstones upon which the future economic development of this and other countries depends. "In our view research as the means by which we expand the frontier of knowledge is today one of the most important factors in the economic and social growth of any modern political society." Society is in the process of freeing man from manual work and dull repetitive jobs. More people are now able to expose their abilities in more rewarding careers, which means that there is more manpower for Research and Development in our society. It is this change in opportunity in our society which has such a major impact on what some call the "conventional wisdom". J. Kenneth Galbraith, the Canadian born Harvard Economist, discussing the critical regions for investment said, "The basic demand on America will be on its resources of Ability, Intelligence and Education. The test will be less the effectiveness of our material investment than the effectiveness of our investment in men". We live in a day of Grandiose Generalization. This one can be made with confidence.

It is in the face of the changes in economics, technology and education that one must consider the problem of health care, medical education and medical research.

It is axiomatic that to participate in the opportunities provided by our society one needs good health. There is no doubt, furthermore, that healthy individuals are better able to contribute to the growth and development of a community than those who are ill. Thus, health care influences the capability of a society to engage in its endeavours. The governments of Canada have recognized that every citizen is entitled to Health Care without worry about financial cost. The question which is not discussed is what quality of Health Care is a citizen entitled to. Can we provide Health Care by simply creating an adequate number of suitably equipped hospitals, Doctors, Dentists, Nurses and other Health Care workers? The answer is no.

In certain of our cities we have a shortage of hospital beds, in areas of this country there are inadequate numbers of Physicians and Dentists, the field of Mental Health is still inadequately staffed and the shortages of nurses and Health Care workers has been publicized in the press. The Governments in Canada have recognized these deficiencies which were clearly outlined in the Royal Commission on Health Services, and are taking steps through the Health Resources Fund and other actions to provide additional facilities and personnel. What must concern us as politicians, educators, citizens and inevitably as patients, is the skill of the Physicians and the quality of their service.

Emphasis has been placed on the creation of new University Medical Schools and the enlargement of existing schools in which to train and educate individuals for the Health Care field. However, the solution to the problem of providing the high standard of Health Care which we expect is not to be found simply in building new Medical School facilities. The education of Medical Personnel is a long, costly and exacting process. At the heart of the training process, particularly in the sciences including medicine, are the Teacher Scientists who staff the Medical Schools, the men and women who combine a driving curiosity that keeps them on the frontiers of new knowledge with an equally compelling wish to teach the younger men and women who will follow them.

This inter-relationship of medical education and medical research, which for the past decade has been emphasized by an increasing number of well-informed and forward-looking scientists and citizens, is epitomized by Morison, formerly Director of Rockefeller Institute in New York:

"Research is today an absolutely essential element in the preparation of young doctors and in the continued education of established physicians. A medical school can no longer prepare a doctor with the detailed procedures for diagnosis and treatment which he will need throughout his later career. The whole art is changing much too fast ... medical schools must concentrate on imparting a broad grasp of the principles of medicine and skill in applying these principles to specific cases. Above all, they must help the students to understand how medical investigation produces new knowledge and how one evaluates the new findings as they appear. This means in turn that most students in good medical schools today must learn the research attitude even though a majority of them may never become full-fledged research workers themselves."

This relationship between research, education and heal thl care was emphasized in the report by The Royal Commission of Health Services.

"Health research is essential to health progress. We need in Canada more and better research and a fully integrated programme to advance our knowledge and to train the scientists and professional personnel we shall require. We thereby set into motion a cumulative process: more research, greater knowledge, new means of maintaining health and combating illness, improved and higher quality health services, better health, rising levels of living and incomes, which in turn enables us to devote more of our income to health research, starting a new spiral of the cumulative process."

Of even more immediate importance to the health and success of medical education is the fundamental role that research plays in attracting competent scientists to staff new institutions and to strengthen existing institutions.

For the brilliant young medical graduates who could become the staff members needed by our medical schools, the lure of the United States is very strong. Not because they want to leave Canada, but simply because opportunities for study and research are greater in that country. Canada graduates nine hundred new doctors each year-and promptly loses as many as two hundred of them permanently to the United States.

They go-and it's usually the best ones who go-because adequate financing provides a productive research environment in the States. The U.S. spends about $6.50 per capita of public funds on medical research each year. Canada spends $1.05!

The Federal Government has already committed itself to spend $500 million on health training facilities, including medical schools, and comparable or greater amounts are to be made available by Provincial Governments. But these schools must be staffed.

Canadians cannot afford to accept the status of an "underdeveloped" nation as far as research goes, living on the fruits of American and European genius. Moreover, if Canada is to capitalize on research ideas she must have adequate numbers of people actively engaged in the research process. The failure to plant, nurture and harvest sufficient numbers of properly trained and critically minded individuals in this country in the past has left us in the position where we are already having or soon will have difficulty in incorporating new discoveries made in other countries into our current medical practices, with the result that the standard of health care will gradually fall below the best practice in the more favoured countries.

The importance of and the urgent need for a solution to staff shortages within medical schools were dramatically underlined this year when it was revealed that one-third of Canadian Medical Schools had received some warning with respect to their accreditation during the past 10 years. These warnings about deficiencies in 4 of the 12 existing Canadian medical schools, if unheeded, would see them placed below the general North American accreditation standards; despite this, we are in the process of expanding the existing schools and creating four new ones. The primary fault in the 4 existing schools was not with respect to their basic orientation or the quality of existing staff but rather that they had insufficient staff and resources to meet the needs of modern medical teaching. For how long can we afford to neglect this situation? When will we recdgnize the need to retain these men in whom we have already invested part of our country's resources? When will we take steps to strengthen our medical schools?

Recognition of these problems by a citizen of this city led him to have the problem reviewed. Mr. C. L. Gundy, Chairman of the Board, Hospital for Sick Children. Toronto, commissioned Woods, Gordon and Co., Management Consultants, to study the problem. Assistance was provided by many people in governments, universities and hospitals, particularly by the Canadian Society for Clinical Investigation, The Canadian Heart Foundation and The Canadian Arthritis and Rheumatism Society.

The resulting report, now called the Gundy Report, to the Government of Canada was personally endorsed by more than 600 medical scientists, by the Deans of the Medical Schools, and by the country's Medical and biological Societies. The main points of the Gundy Report were: (1) That modern medical education and medical research are interlocking functions that are virtually inseparableThis interlocking function depends on a core of teacherscientists, an essential component of the modern Medical School; (2) That such men can only be attracted to and held in a school if a favourable environment has been created; (3) That this favourable environment depends on adequate funds for both capital construction and operating costs; and, (4) That the problems involved in keeping our present slender stock of teacher-scientists and finding others call for immediate answers, because the crisis is already upon us.

A few facts will illustrate the problem. In order to maintain the present standard of health care we will need about 1,300 teacher-scientists in the next 5 years. Under present conditions we cannot recruit sufficient personnel to meet these requirements. We must start now to bring back Canadians from countries such as the United States and make it more attractive for all our graduates to stay here.

The cost of achieving this is to increase support for operating funds from about $20,000,000 in 1965-66 to about $100,000,000 from all sources in 1970-71.

One way of looking at this cost is to take the province of Ontario. The cost of health care and medical education is somewhere in the order of $500,000,000 in this province (this includes all areas). The research cost needed now to maintain our existing Ontario medical schools at an appropriate level is $12,000,000. This is surely a reasonable investment to insure the high standard of an expensive but necessary operation.

To achieve the objectives I have presented to you, the support of individuals such as yourself is needed. An editorial in the Montreal Star, on March 2, 1966, commenting on the Gundy Report had this to say:

"Canadians complain endlessly about their abject position vis-a-vis the United States. But they refuse to face the fact that much of it is simply due to failure to spend money where it will do the most good. We are prepared, apparently, to institute medicare at vast expense. We do little to improve medical science and education upon which, obviously, medicare ultimately depends. The amount of money involved is trifling in comparison to the global budget total.

"The Gundy Report suggests the need is $150 million spread over some years. It would bring medical education up to some decent North American standard. This sum would be less than will be spent on building the causeway between Prince Edward Island and the mainland, a convenience doubtless for the people of P.E.I., but a convenience only. So we build the causeway, let medical science go to pot, and bitterly complain of the 'Brain Drain' to the United States. What a people we are!"

As pointed out in my introduction, the opportunity is there for us to seize it. The choice is a simple one-excellence or mediocrity in health care for Canadians in the. future.

Thanks of this meeting were expressed by Dr. Harold V. Cranfield.