Social justice or medical expertise: What do patients want more from their doctors?

Rhetorical question for patients. One thing to have awareness and understanding of the social determinants of health and to improve data and understanding of health factors that affect different groups, but how will anti-oppression language improve health outcomes:

For over a year Canadian physicians have been debating the CanMEDS roles, which is a framework describing the competencies required of specialist doctors certified by the Royal College of Physicians and Surgeons of Canada. These roles are taught in medical school and form part of the basis for the students’ evaluations.

The roles include physician as communicator, collaborator, leader, health advocate scholar and professional. The central role is physician as medical expert, which integrates the other roles.

In the March 2023 special issue of the Canadian Medical Education Journal, the CanMEDS 2025 interim report was distributed for open public feedback and included a suggestion to centre social justice anti-racism and anti-oppression, rather than medical expertise.

A massive push back from physicians against the decentering of medical expertise arose and has been continuing since publication of the report.

Now, in a March 2024 issue of the CJME, one of the authors of the March 2023 report and others are responding to the negative responses. They claim that opposition to the decentering of medical expertise simply represents “medicine perpetuat(ing) its own power” and maintaining “medicine as an institution steeped in power and privilege.”

This is a deadly serious issue for medical education and for the care of patients. It matters not whether a surgeon is engaged in social justice for the patient who makes it to the operating room. At that point only medical expertise counts.

I learned this during my training at St. Michael’s Hospital in the late 1970s. A man living in a shelter was admitted to hospital for an urgent heart valve replacement. The surgeons saved his life but were not focused on social justice. Their expertise and attention were directed to the patient and nothing else.

Of course, post surgically he had no place to live and hospital personnel had a duty to find him an adequate place to which he could be discharged. But that would be all for naught had it not been for the expertise of the surgeons. That determined everything else. Medical expertise trumped all.

Confronting inequities and racism in health care is inseparable from confronting system-wide and societal inequities. Doctors alone cannot solve that, but they can at least be competent physicians technically and remain current on the science and standards of care for ailing people.

Beyond that they may choose to engage as any other caring citizen and fight fiercely for justice, freedom and truth in the health care system and in general.

They cannot be taught, mandated, and scripted to do so in the detached world of academic medicine. That is elitism at its worst, as if doctors should lead the charge for social justice.

There is a certain personal irony for me. Nearly 20 years ago I gave the first advocacy lecture in the University of Toronto’s Temerty Faculty of Medicine undergraduate curriculum. I stated up front to the students that I was not sure why I was even giving the lecture. I have given the same talk dozens of times since.

Here is how I introduced my talk and then with breathtaking hypocrisy continued on with the presentation:

“In my judgment, all advocacy means is being a socially responsible and good citizen, values both personal and ideological that are part of being a human and could not possibly — and maybe, should not — be taught by the universities. After all, what business is it of medical faculties to be teaching and evaluating political philosophies within the context of a curriculum?

“But how can the matter of advocacy be incorporated into medical practice and medical school curricula? It should be expected that physicians advocate on behalf of individual patients, who might benefit from an experimental therapy for a life-threatening disease. Physicians should actively intervene on behalf of a group of patients who are being denied access to a standard treatment. And physicians must intervene when a neighbourhood is at a health risk because, for example, of an environmental hazard.”

I still do not think that it is the business of medical faculties to be teaching and evaluating political philosophies within the context of a curriculum.

The public, if they were ever asked I am certain, would choose a competent surgeon, if that is all the surgeon could offer. They can secure their social justice elsewhere, with or without doctors.

Philip Berger is an Officer of the Order of Canada and a longstanding downtown Toronto physician.

Source: Social justice or medical expertise: What do patients want more from their doctors?