Clinical Faculty Past, Present & Future

1. Clinical FacultyPast, Present & Future Derryck H. Smith MD FRCP (C) Head, Department of Psychiatry Children’s and Women’s Health Centre Clinical Professor, Division of Child and Adolescent Psychiatry, University of British Columbia 3rd Annual UBCDepartment of Psychiatry Clinical DayJune 11th, 2004

2. 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.

3. 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

4. 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”

5. 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”.

6. 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 teaching Reference: Rae, A. “Osler Vindicated”CMAJ, June 2001, 164

7. “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

8. 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.

9. 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”.

10. 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”.

11. 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

12. The Role of Clinical Faculty • Provide role models • Practicing doctors dedicated to excellent patient care • Advocates for patient care in the current environment of “the corporatization” of health care

13. 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

14. 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 demands • Changing times for CF

15. 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 changes • FOM responds to recommendations with litany of constraints, but no constructive alternatives

16. 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).

17. 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

18. 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

19. 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.

20. 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

21. 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

22. 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

23. 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

24. 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.”

25. 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.”

26. The TASC Agreement Was widely praised and anticipated to usher in a new harmonious and mutually respectful relationship between the FOM and CF. Then………..

27. 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

28. 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 Agreement • One sided in favor of FOM • FOM – no obligations vs. CF obligations

29. Suspension of Student Teaching • January 2001: Negotiations break down • February 2001: UCFA organizes widespread suspension of teaching • March 2001: FOM agrees to mediation

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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.

36. 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

37. 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 Medicine Seconded by PARBC

38. June 2004 • Dean offers to pay all outstanding invoices • Clinical Faculty submit bills for $2.5 million • Dean refuses to pay • UCFA proceeds with commercial arbitration

39. 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.

40. 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.

41. 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.

42. 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?

43. 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

44. 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