JCMS Header

The Future of Canadian Academic Dermatology:
A Personal View

The future of academic dermatology in Canada is threatened. Massive cuts in health and higher education funding are occurring. Specifically, along with health cuts, 4.5 billion dollars in transfer payments committed to higher education will be cut between now and 1998. A further 2.5 billion dollars will be eroded through inflation. Provincial governments are in the process of producing budgets reflecting these realities. Such budget reductions are occurring irrespective of the political party in power. They are being driven by a revolution that is affecting most of the Western world.

Research activity will also be impacted adversely. Research funding is being reduced. The MRC budget has been slashed by 10% over 3 years. Other granting agencies are being cut by even more.

Will our medical schools survive? Will our Divisions of Dermatology survive? How will dermatology rate in the budget priorities of medical schools and hospitals?

Divisions of Dermatology, after a long slumber, are beginning to awaken in Canada. Research efforts are increasing exponentially in many institutions in the country. We have been making up for lost time. We have come to recognize the importance of research in the field of dermatology, and many Canadian dermatologists have been willing to make the personal commitment and sacrifice required to develop investigative dermatology. All that is threatened if we do not develop a rational response to these changes.

How might we address this future? Academic dermatology will survive only if we, as a group, have a clear vision of our threats and our opportunities. Past ways of doing business will not help us. While it is natural to clutch fervently to these past methods and concepts, I believe that the future belongs to those who can recognize the new reality, and act on it. Dr. Martin Hollenberg, Dean of the Faculty of Medicine, University of British Columbia, recently circulated a few specific recommendations that I have modified and expanded into the following list of suggestions.

Plan innovatively and look for new opportunities. Each Division of Dermatology should appoint a committee to examine everything that it does in terms of the new economic and political realities. We will have to become much more entrepreneurial. We will have to examine who we train and why we train them. We will have to examine methods of selling our services to a much broader constituency. Our services include education, with the possible development of distance learning. Our services include research. We must make ourselves relevant to industry. Our services include patient care. Most academic centres have unique clinics. These clinics can be developed and enhanced. In their enhanced form, they will add value to teaching, and to resource development, in addition to raising the profile of the Division of Dermatology within the university and within society. We must be able to market these focused patient services.

Change perceptions. Many faculty members do not understand that they are in the middle of a revolution. This revolution in both health care and university funding is truly profound. Although there is a general unease in the medical community, most physicians, I believe, do not truly understand the nature of the revolution that is occurring. First, power is moving from physicians to patients. Hospital Boards are being established that contain no medical representation. Hospitals are being merged, and resources are directed back into the community. These changes are occurring at a pace that has not occurred before in recorded history. There is a true shift of power from physicians to nonphysicians. It is important that we recognize this and govern our actions accordingly. Second, within the university, tuition fees will rise massively. This will have the result of both impoverishing and empowering students. High tuition fees will lead to greater demands from the student. Again, one is seeing a power shift from faculty, this time to the student. We must therefore increase the quality of our offerings or we will be unable to secure the funding from an increasingly demanding student body. Students, and externally funded residents, will be our customers.

Choose our direction, focus our energy, and build on strength. Divisions of Dermatology in Canada will be unable to be all things to all people. It is important that we begin to focus clearly and consciously on areas of development where we can be dominant. Within some Canadian divisions, our research focusing began a decade or two ago. Toronto can now be viewed as dominant in immunology, particularly cytokines, and ultraviolet light and the immune system. Edmonton is strong in the basic science of the benign melanocyte, vitiligo, and melanin. Vancouver has chosen to focus its research efforts in membrane biophysics ("why we don't leak"), in the gene control of skin cancer, in laser photobiology and skin optics, and in the epidemiology of skin cancers. Focused areas of clinical research have also developed in these and other centres. We must all build areas in which we can achieve true excellence. The days of funding the average are over. Excellence will, in turn, support excellence. It is crucial that we define what business we are in, and stick to that business.

In teaching, we must embrace digital technology. Vancouver, London, Montreal, Toronto, and St. John's are all active in using digital technology to enhance our ability to teach. It is crucial that we build on that strength. Canada has an opportunity to become one of the dominant global players in distance education. We are at least as well placed as any European centre. The United States is active; however, the American Academy of Dermatology has not yet made a major step toward educating the dermatologists and nondermatologists of other nations through distance learning. If we work together as a national team, we can significantly enhance our efforts in becoming a dominant international player.

Prepare for increased competition. Increasing competition will come to academic medical centres in many ways. Nonphysicians will increasingly be able to offer services that dermatologists now provide. We will have to clearly define that which it is we do well and cost effectively. We must equally define that which is best left to others. There is little point in defending the indefensible. We must build on that which we do uniquely, and educate our colleagues and our fellow citizens as to those areas in which we provide the best service at the lowest price. This trend will actually enhance academic medical centres. Much of what occurs in an academic medical centre is the kind of service that will survive coming changes. Academic centres must add value and be seen to add value to our colleagues in clinical dermatology and to our colleagues in the rest of medicine.

Establish partnerships. Divisions of Dermatology do not exist alone. In the past, we have been relatively isolationist. Much of the isolation was the result of the almost entirely ambulatory nature of our patient care. In a hospital setting, we tended to be the forgotten specialty. If we are to survive the coming cuts, it is important that we begin to be active in institutional medical affairs. We must reach out and influence the flow of resources. This is not a time for passivity.

Partnerships include relationships with industry. The companies that bring us better treatments for our patients are not our enemy. Industrial representatives are frequently treated as second class citizens or worse at medical meetings. We must recognize that these people are an important part of our ability to care for patients. Many of these individuals fully share our value system. We must work with industry to develop alternative funding sources for our research efforts. If we add value, we can compete for global clinical trials. We should not just focus on trial development in Canada. Canada, thanks to our fiscal mismanagement, has a devalued currency. On the bright side, this devalued currency allows us to compete in the international arena for international trials. We must work in partnership with Canadian industry, most of which is a branch operation reporting to an international headquarters, to bring more international dollars to Canada. We are best able to accomplish that by working in partnership, rather than competitively, with our colleagues across the country. Internationally, we should support our Canadian partners. We truly must speak with one voice. With one voice, resources will increase. In a divided house, resources will diminish.

Partnerships include working with government. Such a partnership will likely entail an increased focus on outcome analysis. Cost containment is important to all of us. We have long agreed that we should abandon practices that have been shown to be ineffective. Regrettably, there are few properly conducted outcome studies on which to base recommendations. University programs are well placed to participate in furthering evidence-based medicine and to benefit from the increased funding that will be allocated to such studies. Britain allocates 1.5% of medical payments to support health services, as well as clinical and basic, medical research. We should all work with our provincial ministries of health to develop a similar allocation in each province. Funds of this magnitude would significantly enhance our research efforts.

Develop new revenue and resources. The leadership of Canadian divisions will have to recognize these future needs. The more successful divisions will have leaders that are innovative, entrepreneurial, and aggressive. These leaders will actively seek partnerships with industry, foundations, and institutions with parallel objectives. They will work actively to develop patents and other industry-related intellectual property. They will develop external funding. They will define areas of academic focus and will share that vision clearly with those around them. They will have defined realistic goals and objectives and will have divisionwide, departmentwide, and facultywide support for those objectives. They will see their division's role in Canada and in the world.

Develop the international dimension. Linked to offshore clinical trial development and off-shore educational opportunities is the concept of Canada as a partner in the global community. We have, in Canada, universities of international stature. Some (such as McGill, and the University of Toronto) have a reputation that is global. Indeed, the stature of these universities abroad is at least as high as that of all but four or five in the world. We must capitalize on this. We are now part of a global market. We must set our sights on international standards. To aspire to be the best in Canada is a very miserable ambition.

In summary, we must plan innovatively and look for new opportunities; we must change the perception within and without the specialty; we must choose our directions and focus energy, building on strength; we must prepare for increased competition; we must establish partnerships; we must develop new revenue resources, and we must recognize that in order to survive, we must become players in a global market. That market includes our ability to educate, conduct research, and treat patients. The sooner we come to realize, deeply and profoundly, the revolution that is upon us, the sooner we will be able to respond. Canada, as a whole, is a minor world player. If academic dermatology is to survive, it is clear that we must focus. We must devote our resources to these areas of focused expertise, and we must work as a team. With our devalued currency and our awareness of both our problems and opportunities, we are uniquely placed to advance our position in global academic dermatology and begin to seriously contribute to that world effort.

David I. McLean
Vancouver, British Columbia

Presented to the Canadian Professors of Dermatology, Whistler, British Columbia, July 1995.

Reprint requests: David I. McLean, MD, FRCPC, University of British Columbia, Division of Dermatology, 835 West 10th Avenue, Vancouver, BC V5Z 4E8

Top of Article
JCMS Vol 1(1) Contents Page