Over the course of his extraordinary 50-year career, acclaimed physician and Muskoka Algonquin Healthcare (MAHC) Board member Dr. Bill Evans has witnessed the ongoing evolution of healthcare delivery. In this essay, he shares his perspective as a physician and a member of the Muskoka community:
Planning for the Hospital of the Future
It is commonly said that the only constant thing in life is change, and that’s certainly true in healthcare. Over the 50 years since I graduated from medical school at the University of Toronto, I’ve seen enormous changes in how we diagnose and treat illnesses.
When I was an intern working in the emergency department of the Toronto General Hospital (TGH), a patient having a heart attack received intravenous fluids, painkillers, nitroglycerin and we watched for life-threatening arrhythmias and hoped for the best. Our ability to manage heart attacks has changed dramatically. Now, patients are rushed to cardiac investigation units (CIUs) in specialized centers across the province, where blocked coronary arteries are opened up with little plastic tubes (stents) so that the heart muscle can continue to receive the blood and oxygen it needs and doesn’t die. For patients living remotely from CIUs, clot-busting drugs are used until the patient can be safely transported to these specialized services.
When I rotated through the eye service at TGH, patients undergoing cataract surgery came back to a darkened room where their heads were sandbagged to limit movement and they stayed on complete bed rest for a number of days before discharge. Today, patients come into the hospital in the early morning for surgery and, after their procedure, can go for lunch and shopping in the afternoon.
In 2005, when I was the President of the Juravinski Hospital and Cancer Centre in Hamilton, I had responsibility for a large joint replacement service. The average length of stay after hip and knee replacement surgery ranged from 3 to 7 days. Last year, an 80-year-old friend from Muskoka had a hip replaced at the Toronto Western Hospital and came home the same day.
The changes I’ve seen in cancer care have been truly amazing. When I began my practice as a cancer specialist (oncologist), I was dependent on simple X-rays that were incapable of seeing the full extent of cancer’s spread. Now, we have CT scans, MRI scans, and PET-CT scans, which help us define the full extent of malignancy and enable us to target our treatment far more accurately.
The drugs used to treat the various types of cancer have also dramatically changed. At the beginning of my practice, I only had a few chemotherapy drugs to use, and they indiscriminately killed normal and malignant cells and caused a lot of side effects. Now, there are numerous drugs that target the specific changes in the cell’s genetic code that cause cancer, and we’ve learned how to use the body’s own immune system to fight many cancers. Now, the outcomes for many cancers have improved dramatically.
So, change has been a constant feature throughout my medical career, and we can fully expect it to continue and likely accelerate. The change in how we diagnose and treat illness has an impact on how services are organized and what we need in our hospitals today and in the future. Planning for the future is very difficult. No matter how hard experts try, it is impossible to get it 100% right. It’s impossible to know exactly what the new diagnostic and treatment facilities of the future will look like, but we have to try.
The best we can do in designing the hospital of the future within the bounds of available government funding is to be guided by what we see as emerging trends. Several trends are clear.
– The length of stay of patients for many surgeries has markedly reduced because of improvements in surgical techniques (minimally invasive surgery), more effective postoperative care, and the recognition that recovery is often faster and safer in a home environment. So, fewer beds for surgical patients are necessary.
– Of course, we will still need beds for chronic conditions like stroke recovery, for patients with complications from their treatments, and for those who have become deconditioned during a hospitalization. But even for these situations, focused efforts to get patients going again – reactivation – can shorten bed stays and supportive care services from the community can facilitate earlier transfers to home.
We’ve also come to recognize that there is a volume-outcome relationship for many interventions which makes sense. The more you do of anything, be it a procedure or surgery, the better you become at doing it. Cancer Care Ontario rationalized the locations of many cancer surgeries because of clear evidence that the survival of patients was greater in high-volume surgical services. For more common procedures, concentrating them in a facility with high “throughput” will ensure that the whole medical team follows best practices and achieves the best results for patients. The same concept applies to the delivery of babies. The more deliveries performed by the obstetrics team, the safer the delivery is for the mother and child.
Another change that is transforming healthcare delivery is the steady integration of information systems that allow care providers ready access to a patient’s medical history, eliminating unnecessary duplication of history taking and diagnostic testing. We still have a long way to go to optimize this, but there have been substantial improvements in access to digital images, laboratory reports and medical records, which should eventually lead to true integration of care.
One recent and sudden change in the use of technology was forced on healthcare during the Covid pandemic. Suddenly, virtual care became a reality, and consultations and follow-ups were being conducted between the practitioner and the patient’s laptop showing that virtual care was possible. This is not appropriate for all forms of medical care, but it can efficiently enable early hospital discharge, home-based follow-up, and many other time-saving strategies for physicians and patients alike. The hospital of the future will be fully equipped with the information technology needed to enable this type of virtual doctor-patient interaction.
Artificial intelligence (AI) can be expected to have a huge impact on the healthcare delivery of tomorrow. Already, AI-enabled stethoscopes can diagnose early signs of heart failure long before clinicians can hear or see the signs of heart failure. This allows for treatments to be implemented before symptoms and avoids hospital admissions. Chatbots will enable patients and physicians alike to determine what illnesses an individual may have based on their symptoms and laboratory tests. This is going to change the dynamic between doctors and their patients and necessitate change.
One thing is for sure: The world of healthcare delivery will look much different in 10 years’ time, and so the institutions and organizations that provide that care will need to look different and function differently, with much greater integration with care providers and supportive care organizations in their local communities. That’s the challenge that those planning healthcare in Muskoka face.
Rather than settling for a vision of how things are now, let’s embrace the excitement of creating an innovative and integrated system of care delivery that will meet our future needs. The hospital of today, designed decades ago, doesn’t meet our needs now and will not meet our needs in the future. The provincial government is making a major investment in our community that is well above what most communities can expect to receive on a per-person basis. We need to seize this opportunity and boldly create a system of care that will enable and ensure the best care for all Muskokans into the future.
About Dr. Bill Evans
Dr. Bill Evans is a member of the Board of Muskoka Algonquin Healthcare Corporation and Professor Emeritus in the Department of Oncology at McMaster University. His career spans over 50 years of oncology practice, consulting and healthcare administration. He was the CEO of the Ottawa Regional Cancer Centre for 12 years, Vice President for Clinical Programs at Cancer Care Ontario for 5 years and President of the Juravinski Hospital and Cancer Centre at Hamilton Health Sciences for 8 years.
He has published over 300 papers in peer-reviewed journals on various aspects of lung cancer treatment, smoking cessation, and the cost and cost-effectiveness of cancer care and recently received the Joseph W. Cullen Prevention/Early Detection Award at the International Conference on Lung Cancer for his role in implementing smoking cessation programs in cancer centres in Ontario and across Canada. Dr. Evans has had a summer residence in Muskoka for over 50 years.
About the Board of Directors
The Muskoka Algonquin Healthcare Board of Directors is a 12-member volunteer body that plays a key leadership role in setting policies and visioning for the hospital and the delivery of health care in the communities that we serve.
