Healthy Debate

In 2017, the Royal College of Physicians and Surgeons of Canada launched Competence by Design, the most consequential reform of Canadian residency training in a generation. The premise was simple: we can define all the elements that a graduating physician should know or do in practice, and we should only graduate them when a supervisor has actually watched them do the work competently and safely. The framework broke training into discrete clinical tasks, such as managing a patient with chest pain, that a trainee must be observed performing before a supervisor signs off. Nearly a decade later, the architecture is in place. The observation is not.

In modern health care, we still behave as though safety is primarily a function of individual vigilance. When something goes wrong, health-care providers will instinctively ask “what could I have done differently?” instead of addressing a more uncomfortable question “how did our systems make this mistake more likely?” This is understandable as many enter the health-care profession firmly grounded in the principle of “first, do no harm.”

In May, Ontario’s Auditor General released a special report on the use of Artificial Intelligence (AI) in the Ontario government, including medical “AI scribes” that are increasingly being used by doctors, including us. While headlines and coverage focused mainly on so-called scribe hallucinations of these AI note-taking systems, that wasn’t the biggest news in the report.

Many low-income seniors are standing on the edge of a financial precipice. As family physicians and health promoters at St. Michael’s Family Health Team, we do everything we can to support our patients through these challenges. But for every person we help, thousands of others fall through the cracks with no one to catch them.

We cannot build a humane health-care system by forcing families to choose between unaffordable charges and unsafe or unsuitable care. That is not choice. That is pressure disguised as policy.