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The McGill University Health Centre (MUHC) has been promised $800 million by the Quebec government to construct a new teaching hospital, as has the Centre hospitalier de l'Université de Montréal (CHUM). Recently the Quebec Ministry of Heath and Social Services has been promoting the notion of complementarity to encourage the two university teaching hospitals to work together more closely, but the government's version of the concept is out of joint with McGill's. Dean of Medicine Abraham Fuks discusses complementarity and the role of the Faculty of Medicine and the MUHC in Quebec.
Q: What precisely is complementarity?
A: Complementarity is an idea developed by the Ministry to motivate the two major teaching hospitals, MUHC and CHUM, to see whether programs could be run jointly. Their plan is to save money by fusing a program and having that service provided either at the CHUM or the MUHC. That's the government's definition.
That is not the same as our understanding of the idea. We like the notion of working with CHUM. We can both benefit by working together and jointly administering some programs. We like very much the idea that we could pool our resources to create some larger programs which could give added value — by increasing the quality of patient care, by improving the opportunities for research, and by increasing the opportunity to teach residents in that specialty.
How would complementarity work — or not — for McGill?
We have an excellent program in liver transplantation at McGill, doing approximately 40 transplants a year. Université du Montréal also has an excellent program, with about 60 transplants annually. Together we would have a volume of a hundred a year, so teams would work together more often, making them even stronger, and there would be more patients available for research trials. So we would be ahead of the game on research and teaching, as well as patient care. We support complementarity if this is what it means: working together to improve patient care and to enhance teaching and research.
But if you simply take all one hundred patients and put them on one site, each case still costs money, so there isn't much saving, but the disadvantages are very great. If we don't do liver transplants at McGill we lose a major clinical program and our transplantation research suffers. It will also affect our training program, and not only in liver transplantation. The same team with expertise in liver transplantation also does other major hepatic surgery and related operations, and thus we could lose expertise in minimally invasive gall bladder surgery, for instance. So losing the program doesn't affect only the 40 transplant patients, it affects the hundreds of patients who have other procedures performed by the same teams.
How would complementarity affect the MUHC's larger provincial responsibilities?
The MUHC and the CHUM are not two stand-alone institutions — each is the heart of a Réseau Universitaire Intégré de Santé (RUIS). We have the responsibility to help coordinate care for the western half of Montreal, part of the south shore, the Outaouais, the Abitibi, the Cree territories, James Bay and Nunavik. That's 23 percent of Quebec's population and 63 percent of its territory. The MUHC helps serve the students, physicians and patients in that huge area. We believe that the correct complementarity first involves coordinating services inside our Réseau, so that our RUIS partners can offer primary and secondary care, while we offer more specialized care.
How can we make complementarity work?
Our major problems are that the government is doing it for the wrong reasons — to save money — and that their approach is wrong. They should ask MUHC and CHUM to provide a proposal describing the best ways to achieve high quality care, research and teaching. And if we can save money while doing so, all the better. An oversight audit function is perfectly acceptable, as we're publicly responsible and responsive — the government has a responsibility to the population of Quebec, just as we do. But instead of saying "We are giving you public money, show us how you are going to be responsible," they said, "Here is our plan." And imposed complementarity doesn't work.
There have been rumblings in the National Assembly and the press about whether the city needs two teaching hospitals, with some commentators suggesting the MUHC exists because of tradition and demographics — basically, because McGill is an old, Anglo institution.
History and tradition are important to us. They help explain who we are and how we've gotten to our current position, but they are not the reason the government should support us. They should give us the funds to build a hospital because we are part of the future of Quebec. We have a responsibility for a quarter of the population. And we're not an Anglophone hospital — we're a bilingual hospital that treats a large and diverse clientele, including Francophones and allophones and everyone who comes in.
Every city in North America with two or more medical schools has two or more teaching hospital networks: Washington, Atlanta, San Francisco, Oklahoma. Boston, which is a comparable size to Montreal, has three. The Université de Montréal has a great medical school, but some outstanding young francophones want to study with us. They may want to go on to the U.S. to do postgraduate education, for instance, and McGill eases that process because they become comfortable in English here. So the province should be helping us because fundamentally McGill is good for Quebec.
Where does the dialogue stand now?
We've looked at the government's proposal and given them our response. Now we are writing our commentary on pediatric complementarity, also tabled by government, with Ste-Justine. The idea of complementarity can serve us — but we have to carry it out in a way that makes sense.