ALUMNI QUARTERLY
FALL 1998

Over the next six years, McGill will complete one of the biggest and most revolutionary projects to come along in its 177-year history: the creation of an ultramodern "superhospital." The project will involve the controversial closing and merger of its main teaching hospitals into one large health care centre, the rise of a new research institute, and no small amount of revamping in medical education. It will bring together federal, provincial and municipal government bodies, will cost up to a billion dollars, and will change the lives of thousands of health care professionals and many more thousands of Montrealers who will begin using the McGill University Health Centre (MUHC) early in the next century. The very idea of the project has induced anxiety, fear and anger in some, and has others bursting with anticipation.

Four years ago, the first reports of a planned billion-dollar superhospital in Montreal -- which would see the merger of the Montreal General, Royal Victoria, Montreal Chest, Montreal Children's, and Montreal Neurological hospitals, and a much stronger association with the McGill Faculty of Medicine -- started furious debate in the city. Laments went up for the impending loss of historic community symbols like the Royal Vic, and in certain representations the project conjured images of a bureaucratic nightmare of a place, where patients might be lost in labyrinthine corridors or were to be processed on assembly lines in the name of deficit reduction.

It is an image MUHC directors have had to contend with for a while and are quick to try to dispel. An early name change from McGill University Hospital Centre to Health Centre was a semantic refinement, perhaps a better reflection of what the MUHC will actually be when the ribbon is finally cut on the new hospital early in the new millennium. And while they have yet to name a site or propose an architectural model, according to MUHC directors the kinder, gentler health centre will not be a high-rise, corporate-looking complex, but a human-scaled health town made up of low-rise, campus-like pavilions.

In fact, superhospital may be a misnomer. "Who needs 20 storeys?" says Dean of Medicine, Dr. Abraham Fuks, BSc'68, MDCM'70. "We need an institution that's large in vision, large in quality, but not large in physical plant."


"I liken this project to the kind you used to see in the old days when a bunch of men in top hats pulled out a sterling shovel and dug a hole for a museum, a university, the Vic."

Dr. Abraham Fuks, Dean of Medicine

Photo courtesy McGill Reporter

Part of the reason size doesn't matter for the MUHC is the changing face of health care and the modern hospital. One of the current catch phrases on the lips of Quebec health care officials is ambulatory care, or virage ambulatoire, an approach to health care that aims to reduce hospital visits and stays -- and their associated costs -- and which includes all types of services that are provided on an out-patient basis.

"There's less dependence on in-patient care," says the new MUHC Director, Dr. Hugh Scott, discussing emerging hospital practices, "and there's been a major shift towards an ambulatory focus." The result for the MUHC will be a significant decrease in beds and patient stays.

"The modality of delivering care has changed," agrees Fuks. "Twenty years ago, for cataract surgery you were in hospital for four weeks; ten years ago, for four days; now, four hours. Women are not in hospital for seven days after giving birth anymore; men are not in hospital for six weeks after having a heart attack." What this means to Fuks and the MUHC is clear: "You don't need the beds."

The modern hospital is instead part of a network of health care institutions and practices, no longer the focal point it has been since the early days of the 19th century. Joining it along this network are clinics, rehabilitation centres, chronic care centres, and primary care from GPs. It's what Fuks calls a "series of continuities," running along a spectrum from primary to quaternary care and very much in line with the health care outlook held by the provincial government in Quebec. The roots of this new hospital and its philosophy of ambulatory care go back over a decade.

BIRTH OF A SUPERHOSPITAL

In 1992, McGill began taking a hard look at the future of its major teaching hospitals. "There had already been an initiative as long ago as 1986 to look at the possibility of bringing together the Royal Vic and the Montreal General," says Scott. "Both were requiring fewer and fewer beds: in the early 1970s, each of them alone had more beds than both of them combined at this time. So once the examination got going about amalgamating the Vic and the General, then the possibility of adding in the Neuro and the Children's and making what has now become known as a superhospital was a natural progression."

From the University's point of view, it was becoming "impossible to effectively staff all of the teaching hospitals if they were working independent of each other," says Principal Bernard Shapiro. The perspective of the hospitals and the government was a bit different, Shapiro explains, their focus being "How do you sustain quality in the face of diminishing resources?" The MUHC project was a rationalization "not so much to save money as to preserve quality."

Lastly, there was the question of the existing -- and aging -- hospitals themselves. They were deemed impractical, inaccessible, outdated in design, and in such disrepair that to renovate -- just meeting fire standards and correcting immediate deficiencies -- carried an estimated price tag of $436 million, not including any of the redevelopment or redistribution of hospital services which will be central to the MUHC.

"We don't have a single facility that was planned after antibiotics became a medical reality" [in the early 1940s], says Arnold Steinberg, BCom'54, who was named Chair of the MUHC Unified Board of Directors in August 1997, and who has been involved in the planning of the MUHC since 1992.


"Change is difficult, it just is. You have to mourn what passes, as well as look forward to what is coming. These hospitals represent generations of community investment and work."

Principal Bernard Shapiro

Photo: Owen Egan

Likewise, Fuks points out that many of the hospital locations don't lend themselves to modern health care and the virage ambulatoire either, particularly the General and Royal Vic, set atop steep inclines on Mount Royal. "Do you know what it means for a patient to go to the Vic in the wintertime? If a patient can get up that hill to the Vic cardiac clinic in the winter, he doesn't have to be there. If a patient -- heaven forbid -- with an orthopaedic injury is coming back to the clinic on crutches and in a cast, they're risking breaking the other leg when they have to hoof it up to the General from the bus stop."

The idea for building the new health centre "came as a result of a two-year study with representatives from the hospitals and the University, the public at large and the hospital employees," says Steinberg. "They came to the conclusion that A) the hospitals should merge regardless of whether we built the new facility and B) the likelihood is that we could be much more efficient and in the long term pay for the new facility by starting with a new facility as opposed to the five sites that we're currently operating with."

"Leaving these historic properties and going to a totally new site allows us to plan literally from the ground up," says Scott.

SCOTT TO LEAD MUHC

Scott has been charged with bringing the MUHC onto that new site and into the next century. He was named Executive Director of the MUHC in December 1997, and moved back to Montreal this past June. There are few whose experience could match the cardiologist's credentials for running the MUHC project: he taught in the Faculty of Medicine at McGill in the 1970s and again in the '80s as Associate Dean of post-graduate medical education; he founded McGill's Centre for Medical Education; and he was chief physician at the Sherbrooke University Hospital in the late '70s and early '80s. In 1986, he became principal and vice-chancellor of Bishop's University and took that university through campus restoration, major fundraising campaigns, and established it as a symbol of community pride. Just before joining the MUHC, Scott was the executive director of the Royal College of Physicians and Surgeons of Canada. He's known for his ability to get big jobs done and is as politically astute as they come when handling diverse and potentially touchy stakeholders.

"He's had administrative experience, professional experience, and he has ideas about how it is one might proceed in a very, very difficult environment," says Shapiro. "And I think he also has very great personal qualities: when you're trying to bring this kind of thing off, you have to be the kind of person who not only knows how to get disparate groups to work together, but likes doing it, thinks that's fun, interesting, challenging. Otherwise, what you would have is an endless series of civil wars. There are not many who could have brought off [as Scott did recently] the appointment of single MUHC heads of all departments except for surgery and radiology. There's now one Chief of Medicine, not four. Someone who has a combination of knowledge, intelligence, determination, but knows what it's like to deal with people, seems to me a good recommendation for the job."

And while the concept of the new hospital seems to be less controversial these days -- particularly in light of hospital closings in Montreal and cuts over the past few years which have left health care workers and patients alike feeling battered -- Scott will still very much need to bring those people skills into play. Turf wars hampered the attempted merger of the General and the Vic in 1986, and some departments are a little nervous about their place in the new system. There has, however, been an overall turnaround in the opinions of doctors and health care workers, many of whom were vocal opponents of the project when word of the superhospital first broke in 1994 amidst widespread public outcry.

"There was a good reason for that outcry," Shapiro says sympathetically. "Change is difficult, it just is. You have to mourn what passes, as well as look forward to what is coming. These hospitals represent generations of community investment and work. Whole communities developed around each of these physical spaces that have meaning to people and their lives and their imaginings of the future. So you don't just write that off by saying 'Let's get more efficient, guys.'" At the same time, he notes, "People are beginning, I think, to get over that and understand what the possibilities might be, and understand also that if we're going to provide for the future of this community, it's going to have to change, otherwise there's going to be no future."

Arnold Steinberg concurs. "There's now an extraordinary amount of support for the merger within the MUHC, and I would say the biggest criticism that exists is why aren't we moving more quickly."









Four of the MUHC hospitals, from the top: the Royal Victoria, the Montreal General, the Montreal Neurological, and the Montreal Children's




MUHC Hospitals:

The Montreal General Hospital
Royal Victoria Hospital
Montreal Chest Hospital
(already merged with the Royal Vic)
Montreal Children's Hospital
Montreal Neurological Hospital

Cost: $800 million - $1 billion

Funding:
Province to contribute $250 million as per a merger agreement signed by the Minister of Health in 1997

Federal government will be asked for $200 million towards construction of the MUHC Research Institute

Capital campaign to begin late 1998, targeted at $200 million

Balance of funding through a mortgage repaid from operational savings

Tentative Timeline:
Design to begin mid-1999
Construction to begin mid-2000
Centre to begin operations in 2004

Location: A closely guarded secret, but rumours include:
Site of the proposed new Expos' baseball stadium, at Peel and Notre Dame Streets
CP Rail's Glen Yards in Notre Dame de Grâce, near Vendôme metro station
Meadowbrook Golf Course in Côte St. Luc

Staff: 1,000 doctors, 11,000 employees

Projected Trends for 2004:
In-patient cases will decrease by 10%
Average length of hospital stay will de-crease by 35%
Day surgery cases will increase by 40%
Ambulatory service visits will increase by 30%

Still, critics of the Health Centre remain. Annmarie Adams, a McGill professor of architecture, believes a superhospital is just not right for Montreal at this time. "Like many Montrealers," says Adams, "I am worried that an enormous building, located at some distance from the downtown area, will lead to a further erosion of patient care," voicing perhaps the greatest anxiety in the community. Rumours that the proposed hospital site is on the western edge of the city limits have done nothing to assuage that anxiety. Adams also cites articles in the New England Journal of Medicine arguing that superhospitals such as Edmonton's 868-bed Mackenzie Health Sciences Centre "have difficulty preserving a balance between human scale and community scale" and make visitors feel "small and unimportant."

And Adams adds, "The idea of a superhospital for Montreal is not a new one. During the 1880s, the Montreal General had outgrown its premises and was in need of surgical facilities, following the development of antiseptic surgery." But the governors eventually decided amalgamation was not advisable, and "in my view, it's not any more advisable today than it was 100 years ago."

HOSPITAL OF THE FUTURE

Despite this lingering anxiety, the merger itself has very much begun: the MUHC has already established a unified board of directors, single department heads, and single departments of finance, communications, supplies and human resources. Planning committees are working out the myriad details of what the McGill University Health Centre will look like once it is actually constructed and what kind of care it will be providing. It certainly won't be that much feared colossus, but it will still be home to approximately 1,000 doctors and 11,000 employees.

"We'll want a building which as an entity can be modified," says Scott, "which is one of the very real constraints that we're into right now. We want a much more modular setup that can be reconfigured." The hospital will also incorporate state-of-the-art, high-tech equipment, both diagnostic and therapeutic, and will explore the possibility of using robots and automation for transport of charts, specimens and the like, which takes up so much time and labour today. A new information system will be "focussed around patients," says Scott. "It won't just be their chart as we know it, but will store data about any one of us who's ever interacted with the place. It will be a crucial part of this operation."

Dean Fuks outlines some of the technologies he envisions for the MUHC: telemedicine facilities for showing medical students operations that are taking place down the hall, as well as broadcasting MUHC conferences and bringing in information from the outside; continuing leading-edge procedures in areas like transplantation, oncological care, reproductive biology, reconstructive surgery and specialized neurosurgery. Fuks stresses that the high-tech aspect of the hospital will indeed involve machines, but that it is equally and even more importantly conceptual. Revolutionary scientific knowledge and understanding is where the real -- and human -- high technology comes into play. "I see high tech in genetics pervading the entire hospital: DNA-based diagnostic techniques, gene therapy.... People are a little worried about DNA samples and things like that -- but I think this stuff will revolutionize medicine."

The MUHC also expects that its tripartite mission of teaching, research and health care will be more seamless, with research conducted down the hall from the wards and "a lot more synergy inside the system," says Shapiro.

"I think we have to reorganize how we function as a team within the institution and focus on multidisciplinary care," says Scott. "There will be an organizational renaissance in addition to a new building."

Research, which has been an integral part of the past MUHC network, will also take on a new face, with a central research institute under one director (the recently appointed Dr. Emil Skamene). Says Scott, "When you put together the research associated with the five institutions now, plus the faculty at McGill, this will be by far the biggest [medical research institute in Canada]. Walking around the McGill hospitals, I think it's extraordinary what's being achieved with people just stuck here and there, wherever a few extra square feet can be found.

"What we hope to do is pull together the strengths of the five research institutes and put these into one organization which will be mutually supportive without being stifling. Now that's a bit of a trick. The era of the independent swashbuckling researcher is probably gone. And just as the giving of clinical care as part of a team activity is going to be important, I think that research teams will be important."

The centre of much of that research, McGill's Faculty of Medicine, was originally slated to move to the new hospital site, but will now be staying on campus, though some individual departments may still move. "A planning group was set up to look at what the impact on McGill would be if the faculty moved," says Dean Fuks. "They decided if we left completely, it would have a major deleterious effect on the thousands of students who take their training in the Faculty of Medicine. We teach several thousand science students in subjects like biochemistry, microbiology, physiology, pharmacology and so on, graduate and undergraduate students, who need to be on campus."

Fuks will nonetheless make sure the faculty has a presence on the hospital site itself, and expects every aspect of the hospital to be rigged for teaching -- in conference rooms, research labs, and at the bedside, "keeping the patient the focal point of our teaching," he insists. "It will be easier for students because the environment will be more adapted to students than our current hospitals are able to be. They'll learn more and have a good time learning it." They will also be moving into the community in their studies, since the ambulatory focus of the MUHC will require familiarity with all aspects of the health care network, from primary care physicians to walk-in clinics to chronic care facilities.

What kinds of care the centre will provide is still in the planning stage, though it will range across the spectrum. "Some of this is fairly easy," says Scott. "We want to be at the leading edge of the so-called tertiary/quaternary care. So we wish to continue doing transplantation surgery, heart surgery, major medical illnesses. Where it gets tougher is when you go further down the care chain and ask how much primary care do we wish to have. We know we want to have an emergency room and trauma. Do we wish to be following people for common chronic illnesses? Will anybody have their appendix taken out there? How many hernia operations will be done there? Important things to do, but certainly things that can be done at many other places. Those questions have to be answered."

This doesn't mean we'll all be finding ourselves dumped in the streets after a hospital visit. Central to the MUHC philosophy, planners say, is a focus on providing a healing environment, partly through an approach to care which takes the emotional and social needs of patients into account, and partly through design, which will include private areas for family visits and discussion with doctors, atriums, open courtyards and gardens. "Our expectation is that this will be the kind of site where we can put in things like bicycle paths," says Scott, "and there will be attention paid to the landscaping: it will be a pleasing place to visit, quite aside from trying to get health care. We hope that it will be a healthy part of the city in itself."

TOUGH ROAD AHEAD

Getting things off the ground will still be a job fraught with a variety of perils for Scott and his colleagues. The MUHC deficit stands at $45 million (based on an operating budget of $400 million) and may reach $65 to $70 million by the end of this fiscal year. The project itself is estimated to cost at least $800 million, with funding coming from provincial and federal government support, private fundraising -- a major campaign is expected to begin later this year -- and from savings that will accrue by consolidating the existing system onto a single site. Then there are the logistical difficulties of merging and moving all the different medical departments to the new centre, not to mention ensuring that the heritage sites they're leaving will be properly maintained or developed. Groups like Heritage Montreal and Friends of the Mountain will be watching closely, and Scott says he expects to work with them to find an appropriate solution to the problem.

But the proposal for turning some of the buildings like the Royal Vic -- a classic example of Scottish baronial architecture based on the Royal Infirmary in Edinburgh -- into luxury condominiums and apartments leaves some onlookers cold. "Since the land and buildings were either donated expressly for public use or acquired and constructed with public monies, I'm against it," says Annmarie Adams, "particularly since there's no demonstrable need for luxury housing downtown."

Finally, there are the difficulties inherent in adopting a more ambulatory focus as well. Since the virage ambulatoire has become common parlance in Montreal, reviews of the system are generally poor. Access to alternate care facilities is irregular, people don't necessarily know where or when to go, and the majority still end up in emergency rooms for minor complaints. With the MUHC and its ambulatory approach more dependent on the network of clinics, community practices, chronic care facilities, and "storefront" health care, creating better links to such centres and studying the network itself will be vital. "We have to do research," Fuks concedes. "Why do patients use certain elements of the health care network more than others, and how can we improve the quality?"

MONTREAL RENAISSANCE

Wherever the Health Centre ends up, Montreal real estate speculators are counting on it to raise property values. When word broke in a Saturday newspaper that the MUHC had signed an offer for the land, Principal Shapiro's home telephone rang all day. A few callers even said they were willing to pay him to reveal the location. Asked how many bribe offers came in, he answers with a smile, "More than I would like to have received." It's just added a little novelty to a project that is exciting enough for Shapiro, who has made it one of the University's top priorities.

For Dean Fuks, the MUHC project is "the most important project for the faculty, the University, and its hospitals since the war. I liken this project to the kind you used to see in the old days when a bunch of men in top hats pulled out a sterling shovel and dug a hole for a museum, a university, the railway, the Vic."

"It's also a very important part of the renaissance of Montreal," Hugh Scott observes. "We think this is a Montreal project, we think it will be of major importance to the continuing evolution of this rather remarkable city. The reported death of Montreal was somewhat premature."