Clinical FacultyPast, Present & Future

Derryck H. Smith MD FRCP (C)Head, Department of Psychiatry

Children’s and Women’s Health CentreClinical Professor, Division of Child and Adolescent Psychiatry,

University of British Columbia

3rd Annual UBCDepartment of Psychiatry Clinical Day

June 11th, 2004

The History of the Medical School

Grew out of the guild system in the middle ages

Knowledge was carefully protected (largely from classical Greek texts)

Apprentices were accepted into the guild; similar to blacksmiths, jewelers, etc.

The History of the Medical School

Mid 19th century, an explosion of “for profit” schools in North America

State Boards refused to accept the poorly trained graduate

1907 – AMA forced to close 40 schools

The History of the Medical School

Abraham Flexner, appointed by the Carnegie Foundation

1910 – “Medical Education in the United States and Canada”

Influenced by Rudolph Virchow “medical practice is nothing more than a minor off-shoot

of pathophysiology” The training of future doctors would be the

responsibility of salaried faculty in universities with a “research function”

The History of the Medical School

1911 William Osler, Chair of Medicine Oxford

Osler was not a researcher, made no new discoveries, made his living as a clinician “I can imagine nothing more subversive to the

highest ideal of the clinical school then to hand over our young men who are our best practitioners to a group of teachers who are ex-officio out of touch with the conditions under which these young men will live”.

The History of the Medical School

Flexner’s view prevailed and the medical schools evolved in facilities in which salaried faculty pursued a research agenda

“Teaching” – using charity patients To many, teaching became a chore of

secondary importance to research Clinical faculty were engaged to perform the

teachingReference: Rae, A. “Osler Vindicated”CMAJ, June 2001, 164

“No Place to Learn”“Why Universities Aren’t Working”

University research often detracts from the quality of teaching

Teaching involves different skills and imposes different obligations than research

1936 Robert Hutchins, President University of Chicago “Students who are going to be teachers are put through a

procedure designed to produce researchers”

Reference: Pocklington, T and Tupper A., “No place to Learn – Why Universities Aren’t Working”, UBC Press 2002

No Place to Learn

“No modern institution is so rife with jealously and a sense of oppression than the modern university”.

Sessional lecturers resent tenured professors.

No Place to Learn

Dedicated teachers often despise researchers who ignore their students with impunity.

“The critical pursuit of research as a university priority has weakened the universities’ commitment to student life and the quality of education”.

No Place to Learn

First year teaching has been abandoned by senior staff and assigned to “sessional lectures” with class sizes of over 600 students.

“No Canadian university in recent memory has hired a senior professor from another university because of his or her demonstrated teaching skills”.

The Role of Clinical Faculty

Provide high quality teaching Advocate for the primacy of teaching Fulfill our ethical obligations of passing on

practical skills and knowledge to the next generation

Hold the Faculty of Medicine accountable for ensuring that the teaching enterprise is appropriately funded – especially in times of expansion

The Role of Clinical Faculty

Provide role modelsa) Practicing doctors dedicated to

excellent patient careb) Advocates for patient care in the current

environment of “the corporatization” of health care

A Chronology of Events

Relationship between the Faculty of Medicine (FoM) and Clinical Faculty (CF)

University of British Columbia

Reference: Chan-Yan, C. Department of Medicine, May 2004

Relationship between FoM and CF

1980’s Informal and arbitrary

No written terms of appointment Various styles of interaction from collegial to

coercive Initially tolerated, situation deteriorated

Increasing FOM demandsChanging times for CF

FM Clinical Faculty Committee

During the early 1990’s: - Dean Hollenberg Committee attempts to improve conditions Successive Chairpersons report

Innovative recommendations, including the Smith Report – based on polling of the clinical faculty

Resulted in minor changesFOM responds to recommendations with litany of

constraints, but no constructive alternatives

SPH Clinical Teachers Association (CTA)

Spearheaded by Dr. Angus Rae in 1991 “A man without a stick can be bitten, even by a sheep”.

Gains achieved: UBC-SPH Affiliation Agreement changes

Terms of appointment to FM and SPH Removal of requirement for “Practice Plans” (Changes not with FoM agreement, but with pressure on Hospital

administration).

External Review FM Finances

April 1995: FoM recorded a debt of $5.6 million “...morale is in danger of diminishing

throughout the Faculty, but it is at a seriously low ebb amongst the clinical faculty who feel that they are not rewarded or recognized for what they do.. ”

CF not aware of report, but are pressured to form “Practice Plans” to support FoM

University Clinical Faculty Association (UCFA)

Formed in 1998, A voluntary association of about 500

clinical faculty, formed to negotiate conditions of work, remuneration and other issues, with the FOM

Infamous Cardiology Motion

June 1998 - All DoM Divisional Secretarial support discontinued.

Motion passed, widely supported by others: No further teaching of medical students unless

secretaries returned and discussion between Dean and Cardiology regarding future arrangements and mutual expectations.

Infamous Cardiology Motion

Possibility of wildfire withdrawal of teaching Dean Cairns convenes urgent meetings Task Force Committee (TASC) initiated

jointly by UCFA and the FoM Relationship to be defined Cardiology agrees to await report

TASC

Chair: Monique Bertrand Members: 5 CF (3 UCFA; 2 FOM); 3 FT;

Dean’s Administrative Assistant Facilitators: Qualstar Solutions Inc. Convened in December 1998: meetings

conducted through 1999

The TASC Agreement

“Mutual Responsibilities and Obligations for Clinical Faculty and Faculty of Medicine”

Submitted by Dean to Faculty Executive Unanimously agreed and passed October 1999 Dean instructed to commence implementation Signed by Dean and President of UCFA

The TASC Agreement

Outlined functional arrangements Scheduling; resources; inclusion & consultation Principle of appropriate remuneration

CF rights, including representation rights Detailed implementation plan with timelines

included

The TASC Agreement

“The Faculty of Medicine recognizes the right of the Clinical Faculty to have independent representation in its dealings with the University when defining the roles, responsibilities, rights, and rewards of Clinical Faculty members.”

The TASC Agreement

“Individual Clinical Faculty members will have the right to choose how they are to be represented. The Faculty of Medicine recognizes the right of Clinical Faculty members to form an association. If an individual Clinical Faculty member chooses to be represented by an association, the Faculty of Medicine recognizes the right of the association to be the sole representative of that Clinical Faculty member.”

The TASC Agreement

Was widely praised and anticipated to usher in a new harmonious and mutually respectful relationship between the FOM and CF.

Then………..

Chronology continued…

The months pass by – no movement regarding implementation of the TASC agreement.

April 2000: Cathy Cordell instructed to represent UCFA re negotiations for service contract.

Negotiations commence August 2000 Team: D. Smith; C. Thompson; J. Wade

Behind the Scenes

While negotiations proceed: Dean makes announcements and distributes

opposing documents. FOM expedites CASC process with Hospitals

and Government:Terms contrary to TASC AgreementOne sided in favor of FOMFOM – no obligations vs. CF obligations

Suspension of Student Teaching

January 2001: Negotiations break down

February 2001: UCFA organizes widespread suspension of teaching

March 2001: FOM agrees to mediation

Mediated Agreement

Mediator: Judith Korbin FOM team includes the Dean, a VP Human

resources, UBC August 2001: Final A/O Letter drafted –

FOM attempts to insert “unauthorized” footnotes

Mediated Agreement

Appointment/Offer Letter for Individual CF Terms of appointment Payment schedule, including teaching combined with patient care $80 per hour Clinical teaching:

Students - $ 24/hour Residents - $ 8/hour

Definition of “assigned” teaching Dispute resolution – commercial arbitration Teaching tracking project funded by FOM

June 2001: Approved at Faculty Executive

More of the Same

Months pass by, invoicing system in chaos Individual and group invoicing No system of tracking/responding No payments; no responses from FOM New Dean – Gavin Stuart

Dr. Brad Munt takes his teaching invoices before a commercial arbitrator

UBC lawyers argue that clinical teaching has no value

The Munt Affair

Arbitrator: Murray A. Clemens, Q.C. Counsel for Claimant and Respondents. April 2003: Arbitrator jointly appointed. October 2003: Arbitration award submitted UBC lawyers repeatedly slow the process

The Munt Affair

Summary of Arbitration: Munt’s teaching was “formally assigned” as

defined in agreement Teaching services are compensable at $8.00/hr

(“nominal”) Munt awarded costs of arbitration

FOM Response to Arbitration

Initial refusal to abide by decision. Munt “fired” and no longer assigned

teaching, but has “obligation” to teach residents who happen to appear on his service!

Dean unilaterally moves to re-define terms of A/O Letter; and teaching of residents is “declassified” as “Formally Assigned” and converted to “Obligation” of CF.

Faculty Meeting November 13th, 2002

Resolution to not support Medical School expansion unless: Government in writing commits to increase

residency positions. FOM must undertake study of current and future

human resources for clinical teaching. Clear implementation plan must be in place.

Seconded by PARBC

Faculty Meeting May 12th, 2004

Failure of FoM to enact motion November 2002: Resolution recommending that the University

Senate delay implementation of medical school expansion until detailed: Review of human resource requirement. Financial report addressing all aspects of expansion

presented to the Faculty of MedicineSeconded by PARBC

June 2004

Dean offers to pay all outstanding invoices

Clinical Faculty submit bills for $2.5 million

Dean refuses to payUCFA proceeds with commercial

arbitration

Interpretation & Summary

FOM has shown no sincere interest in resolving CF concerns – twenty-year record.

FOM responds only to threat of withdrawal of teaching (1998 and 2001).

The TASC Agreement has been betrayed. Negotiated A/O Letter – was never honored

and is now thrown out.

The Future

We must balance the teaching versus the research agenda.

We must continue to hold the Medical School accountable for appropriate financing of the teaching enterprise.

We have the authority to accomplish this thru the collegial governance structure of the Faculty of Medicine.

The Dean and Faculty Executive are responsible to us, not the other way around.

Representation

The UCFA has been formally accepted as a member of the Canadian Association of University Teachers

CAUT has a rich record of defending clinical faculty – eg. Nancy Oliveri

We will seek formal representation either thru the Faculty Association or the BCMA, to achieve an enforceable collective agreement.

Ontario – Global Contracts

A history of Practice Plans with “taxation” 1990 – Sick Kids – Department of Pediatrics Mid 1990’s – Queen’s University 2004 – OMA/Government $75 million to move

2,700 clinical faculty to global contracts $75 million to complete the move Autonomous governance structures Legal partnership agreements Cessation of Fee-for-Service

Is this the model we want to pursue?

Psychiatry – “A Hot Bed of Apathy”

We enjoy enlightened leadership – Thanasios Zis Integration with GFT staff and appreciation of

clinical faculty SESSIONS – payment has never been an issue Relatively well-paid clinical work

Stan Semrau Well represented

Val Gruson

Your Role

Hold the FOM and Dean accountable for funding, especially the expansion

Assert the role of excellent clinical teaching, recognized by appropriate remuneration, within the FOM

Support the UCFA by joining www.ucfa.ca

Attend FOM meetings and vote