What's Wrong with Healthcare?

Thinking inside and outside of the healthcare box. After 41 years of family practice, what's happened to Canada's healthcare system?

Monday, February 27, 2006

A Blog Holiday

Well, it’s time to take a blogging break! Will be posting again in ten days time. Stay healthy.

Saturday, February 25, 2006

Curing Cancer

One of the great things about being a politician is you can make grandiose statements about future events, (like twenty years down the road), take credit for it, but not be around twenty years down the road to be held accountable. My kids still hold me accountable for things that I did and said thirty years ago.
Take, for example, our previous Prime Minister of Canada. He was going to fix health care for a generation back in 20004 and it seems we still have a few problems. Our Alberta premier Ralph Klein is going to put one billion plus dollars into cancer diagnoses and treatment in Alberta and decrease cancer deaths by fifty percent. I really doubt that either of these gentlemen arrived at those statements through any kind of scientific process. It reminded me of Craig Ferguson on the “Late, Late, Show” when he makes an outrageous statement, then states: “Actually, I just made that up, but it IS possible, it is, really, actually it is POSSIBLE”.
About ten years ago one of Alberta’s deputy health ministers, while talking to a large group of women in Toronto made the statement: “Although Canada has spent many billions of dollars on diagnosis and treatment of cancer in the last fifty years, there are as many people who die of cancer today (per thousand population), as there was fifty years ago. Although the statement is likely true, this statement and premier Klein’s, reveal an incredible naivety of medicine and medical statistics, and are probably made purely as political statements.
Let us examine the ways to reduce cancer deaths in Alberta. One of the obvious ways would be by shortening life expectancy. Since most cancers are age related, we could forget about seat belts, helmets, treating cardiovascular disease, etc, which would prevent people from getting old and therefore prevent cancer. We can only hope Mr. Klein was not thinking of applying this form of “cancer prevention! Perhaps I’m being a bit facetious, but the point that needs to be made is; “the longer our life expectancy, the more likely we will develop cancer. The corollary to this is: “The better we prevent and treat other causes of death, the more people will die of cancer”. Everyone eventually dies and there are a few major things we die from; cardiovascular disease, vital and multiple organ failure, cancer, trauma, suicide, infections, and progressive degenerative diseases. As we improve in our prevention and treatments of other diseases, more deaths will occur from cancer unless prevention and treatment of cancer keeps pace. In the last ten to fifteen years incredible strides have been made in the prevention and treatment of strokes and heart attacks. Many of these same people now die of cancer instead of their cardiovascular disease. This does not represent a failure of cancer treatment or prevention, but reflects a huge success story in the treatment of cardiovascular disease. If we ever have a program for identifying and adequately treating the 65% of our hypertensive and hyper-lipidemic patients who are not being treated, or who are inadequately treated, we will see further significant reductions in cardiovascular deaths and further increases in cancer and degenerative deaths.
There has been much talk about the increase in Alzheimer’s disease in Canada. Like cancer, this reflects to a large degree the increase in life expectancy. Is it reasonable to expect that our treatments of non cancer conditions is going to stand still, and that life expectancy will not continue to increase? I would hope not. All the life style changes that are beneficial in preventing cancer would appear to have a positive effect in preventing other causes of mortality as well. Furthermore, the factors influencing the incidence and treatment of cancer are complex and multifactorial. Although cancers have many characteristics in common there are also many different cancers that have unique characteristics. The likelihood of making one grand discovery that can be applied to all cancers is slim to none.
An early diagnosis usually has a beneficial effect in treating and curing cancer. Does that mean we are going to have more family doctors with better access to specialists and diagnostic tools? As an editorial in today’s Calgary Herald suggests cancer treatment and prevention needs to be looked at within the context of our total health care. The only significant statistics regarding cancer are:
1) cases per 1000 population/age specific,
2) Length of life from date of diagnosis,
3) Average age of cancer patients at the time of death, and
4) Quality of life from the time of diagnosis until death.
Using the above criteria we can measure progress.
It is possible that the Alberta Government will propose a type of Northern Mayo Clinic. Although this would have some positive aspects to Albertans, the primary benefit would be to Canada as a whole and then only if other provinces would agree to utilizing it. To obtain expertise and world recognition there must be a sufficient volume of patients to justify the latest in equipment, treatment modalities and professionals. Having two such centers in Alberta flies in the face of this type of project.
It would appear mostly our Premier is looking for an acceptable place to spend money and establish some kind of legacy. All the talk of cancer prevention and a fifty percent decrease in cancer deaths twenty years from now is just that-----talk.

Friday, February 24, 2006

Spiraling Costs

I see the news media is once again quoting Richard Plain, the Edmonton based health care economist. Last I heard of him was some fifteen years ago when his usual song was to cut the fat in health care by reducing doctors and reducing hospital beds. At that time Calgary had 3.3 hospital beds per 1000 population and the conventional wisdom was to decrease this to 2.5 beds per 1000 population. We are now at 1.6 beds per 1000 population in the Calgary region, and Calgary is estimated to be almost 300 family doctors short. Yet the region is asking for a 17% budget increase in spite of an average 7% annual increase over the past seven or eight years. Predictably, Dr. Richard Plain suggests anything that Mr. Klein comes up with won’t work; thankfully, he apparently didn’t make any more suggestions on fixing the situation (once again). Predictably, the news media goes back to the cow that gives the milk (makes a headline), even though the milk given is sour.
The HMOs in the U.S. showed years ago that the more family doctors there are in a population the lower the health care costs per person. I will predict that until we restore the ratio of family doctors to population in our region, costs will continue to spiral.

Thursday, February 23, 2006

Reading Between the Lines

Health care seems to have taken a prominent position in people’s minds these days. In Alberta the news media complain that there is little information forthcoming on Ralph’s “third way”. In Ontario there seems to be an issue with a “French only” community clinic and its refusal to give service to an ill, English speaking Canadian citizen. And in the halls of our esteemed Canadian Medical Association, there seems to be a problem with free speech or something to that effect. The truth is the average citizen hasn’t a clue what is going on and neither the powers that be, or the news media (as I referred to in yesterday’s blog), or both, are too keen on informing the average “Joe”. So let’s speculate.
First it’s not surprising that nothing is forthcoming about Alberta’s third way. How do you bring forward anything in health care that cannot be misconstrued? It reminds me of the commercial of this fellow who is trying to quit smoking; every time he tries to take a cigarette from the package he gets “zapped with an electric shock. The harder he tries the more he gets zapped. I really don’t see much on the horizon from Ralph that is going to make much of a difference, but you can be sure it will be blown up into some kind of “beginning of the end” of Medicare. Now that the election is over we have to fill the newsprint, and after all, Prime Minister Harper said he would protect Medicare, etc, etc, etc. Ralph is going to get “zapped” no matter what he comes up with!
The bloggers have been onto the Ontario lady being turned away from a “French Only” Medical clinic for the past two days. Incredibly, most thought it had to do with language (as did Don Martin in today’s Calgary Herald), when in fact I would think it has primarily to do with money; the very thing that in Canada is NEVER to influence the medical care we receive. Although this clinic was probably set up as a political “show piece” to show how much the Ontario Government Values its Francophone population, it is probably one of our new innovative “globally funded” health care units. These units are provided a fixed amount of money annually by the government or Health Region based on the number of people who have registered (signed up) to receive medical care from the clinic. In effect it functions much like a very elite private clinic but is taxpayer funded. Various formulas exist to calculate the funding based on age and other criteria. Usually those criteria are medical and it would indeed be interesting if one of the criteria is “language”. It would appear in this particular case the Medical Clinic (often called Community Health Care Organization or some other politically acceptable name) may not have had a provision in there agreement with government, to be funded for people that were not registrants, or perhaps the clinic deemed it too much trouble doing the paperwork. In any case, I’m sure the Clinic, in their agreement with government, has the right to reject “Non Members” irrespective of language. Allowing direct payment by a non member would create even more of a stink.
One has to keep in mind that few politicians who have any experience in the health care field, are going to say anything bad about the above scenario. The have been sold on the idea of these clinics being the salvation on the cost part of the health care equation. If all of the public were signed up with Government Health Clinics they could calculate an annual budget for health care. People could not “shop around” or “double doctor” and the responsibility for containing cost will fall on the providers. In many of these arrangements, the provider may be put in the situation “Do I order this test and X-ray or do I give myself a raise this year?” The appropriate term for this is: “Conflict of interest”.
It is interesting that Dr. John Hoey, editor of the Canadian Medical Journal, was recently fired (in spite of ten years of extra-ordinary work) along with his assistant, by the owners of the Journal---the Canadian Medical Association. He apparently had accused the Canadian Medical Association of censorship. It would appear that Dr. Hoey had some interesting information on the new process whereby pharmacists are prescribing the “morning-after-pill”, and wasn’t allowed to publish this information (it’s called censorship in my dictionary). I strongly suspect he may have had some negative comments about the process, such as questions asked about frequency and when the patient last had unprotected intercourse, and the privacy in which these questions are being asked. The issue would go to the relevance of the questions asked and the privacy concerns of the patient. I would suspect the question is being asked in an attempt to determine if the patient could already be pregnant, and therefore the pharmacist may wish not to dispense the morning-after-pill. I would think combined committees of the Canadian Medical Association, the Canadian Pharmacy Association and the Federal Department of Health should have determined the appropriate questions to be asked, and assured privacy during the interviews. Unfortunately, there is no medical evidence to suggest that taking the morning-after-pill is in anyway harmful to the fetus or mom if taken when she is already pregnant. In short, this looks more like delving into personal sexual “history taking” for reasons that are not clear. Exposing this would not speak well for our federal bodies involved, and represents a set back for one of the new bright innovative ideas of making primary care a multiple personnel contact sport! It seems obvious to me this is medical news and should be printed; the Canadian Medical association thought otherwise for obvious reasons and fired an extremely capable editor.
During the hepatitis blood scandal one member of the investigative panel said “When doctors become business people who do we turn to for medical advice?” Now we can ask another question: “When reporters and their publishers become politicians, who do we turn to for medical news?”

Wednesday, February 22, 2006

Are Traditional Journalists Failing Their Duty to the Public?

February 19/06 Calgary Herald had an informative piece on cancer drugs and the huge disparities in coverage from province to province of various medication treatments. There were quotes from reputable physicians pointing out the rational of this discrepancy and it seemed obvious to me that the various Cancer Clinics “criteria” vary from province to province. When I looked into the tamoxifen issue many years ago I was told there was no evidence that the drug didn’t impact breast cancer “survival” although there was eight years of evidence that it significantly reduced breast cancer recurrence. I wonder if some of that archaic thinking still impacts whether a cancer drug is covered or not. From my perspective the yardstick we should be using is: “does it add to our cancer-free years and how do the side effects of the new drug compare to the traditional drugs?” Remember, it is not just length of life we should be looking at, but also the quality of life.
This report stated that a patient had to pay $10,000.oo over the past 10 months for his cancer drug. It sounded like he was getting this drug administrated in Calgary’s Tom Baker Cancer Center. Although the drug company involved has a “compassionate” list of free recipients, it wasn’t clear to me whether everyone who had this type of cancer was able to be put on this “charity” list and, who determines whether someone must pay or not. Are there some Albertans who are getting expensive drugs from our government funded Cancer Clinics by paying for them and some who are not, for financial reasons. If this be true, is this not a two tiered system within a government institution? How is this different than getting the most recent advances in cardiac surgery at the Foothills Hospital by paying for it, but if you can’t afford it, and there isn’t a charity that will foot the bill, you do without.
My main point is that I think only half the story was reported. Is it possible that in Alberta I can get insurance for medications not covered by Blue Cross (seniors plan), or the Cancer Clinic. Obviously, in this case, Blue Cross was not picking up the $10.000.oo tab. for this senior. How am I to know what the Cancer clinic covers or the Blue Cross Plan for seniors covers, and what it does not? Most of us assume that any drug or medical procedure that is purported to be useful will be provided in our care, but obviously there are differences of opinion in “what is useful” or in the definition of “useful”. The bottom line is that we are led to believe that we don’t need insurance and are in fact prohibited from having certain types of insurance but may be faced with significant health related bills for significant disease. The article in the newspaper did not say whether in Alberta insurance is available for these things.
Generally speaking, medical matters are covered very poorly in the Main Stream News Media. Every time we turn around someone is quoted as promoting a two tier medical system, or it is stated that we are moving towards an “American-style” or “American-like” system. In fact, we already have a “multi- tier” system and attempts are being made to move towards a “European style” health care system. The news media, I believe are well informed and know all these things. For some reason they prefer to quote the spin of the “Friends of Medicare”.
Another article that hit the news stands both provincially and nationally was a pilot joint replacement project that supposedly “shortened waiting times to four months. Where did it start out in terms of waiting times? Was this for one orthopedic surgeon, all of Calgary, or the entire province? I understand that hospital stay was decreased by two days but there would be an increase in cost for “pre.” and “post.” operative out patient care. Were the surgeons involved given more operating room time?
Apparently this project was funded to the tune of $20,000,000.oo. What did the budget for this money look like (where exactly did it go) and where were the cost savings aside from early discharge from hospitals. Was there a more rapid turnover in the operating rooms and if so, why, because most joint replacement surgeons have been “block-booking” their surgery for years and supposedly the hospitals have been booking them in a cost effective way. Was there more equipment purchased so that time loss for sterilization no longer was a factor? Supposedly, this appeared to be the “Messiah” program for joint replacement surgery, and waiting lists were the number one concern of Canadians in the last election, and all we get is “Emerson” crossing the floor week after week in the mainstream news media. The pilot orthopedic program, on the other hand, is presented with few details and a positive spin with little justification that I could see. It may be a move to more efficiency, but it isn’t going to save our present Universal Health Care System. At times one might get the impression that the news media prefers confusion and disharmony and an “oh dear, what can be done attitude” in the health care field. I suppose it makes good headlines. Isn’t it time we had some responsible journalism on health care. Some glimpses of other systems that are functioning better would be helpful and positive (such as some of the European systems or the New Zealand system, previously mentioned in my blogs). It may even encourage politicians to move forward on true health care reform. As it is now, the news media serves as an enabler of stagnation and inaction. Any suggestion of a move forward by a political party is portrayed as “American- like”, but at the same time the status quo is reported as unacceptable. Every once in a while a pseudo “breakthrough” big story can be reported, like our orthopedic program, and so we keep limping along, giving mouth to mouth resuscitation to our dying Canadian Identity----Universal Health Care.

Tuesday, February 21, 2006

What Was He Thinking?

Today I am mad! This morning when I woke up at 5:30 A.M. I was mad, and I’m still mad! Perhaps I shouldn’t write about isolated medical events, and perhaps I shouldn’t write a blog when I’m angry, but it is my blog and the title to it is “What’s wrong with our Health Care” so here goes.
Last night when my wife was talking to her friend on the phone, her friend mentioned that her husband had a strange spell six weeks ago. Apparently he suddenly fell at home for no reason, breaking a coffee table. Picking himself off the floor he noted that he was wobbly and unsteady but decided to go to the closest town for some supplies. The nearest town did not have what he wanted so he ventured to the next town, a twenty minute drive away. He noted that when he was driving, the car kept drifting to the left, never to the right. A short while later while waiting in line at a store, he once again found himself on the floor. He drove home and called his wife. His wife stated his speech was slightly slurred (he had consumed no alcohol). When his wife got home she thought there was some slight irregularity to one side of his face. They went to an urgent care clinic.
I know this man as a neighbor, not as his physician. He is 61 years old, and I would estimate his BMI to be in excess of 30, his waist to be in excess of 40 inches and he tells me that when he was seen at the urgent clinic his Blood Pressure was greater than 190/100. He has been on blood pressure medication for ten years and apparently was tried on cholesterol lowering medication but got leg cramps, so he has been on nothing for cholesterol. He is a 40 pack years smoker although he stopped smoking three years ago. His father had a myocardial infarction followed a year later by a stroke that ended his life. This man has at least six risk factors for vascular disease.
At the conclusion of their visit to the urgent care clinic a chest X-ray had been done, blood drawn, and an EKG was done. I would hope with the blood work a tropinin was done to help rule out heart damage. Apparently, blood gases showed a “low oxygen level” so pulmonary function tests were ordered for three months down the road. I’m not sure what the chest x-ray was for. If they were thinking about a pulmonary embolus a chest X-ray was not likely to help. He would have needed at least a lung scan. He reported no sweating, fever, chills etc. so pneumonia was highly unlikely. His BP was elevated on arrival and he had no abdominal pain so one can exclude an Abdominal Aneurysm leak. They excluded a myocardial infarct---so what is left. Some lateralization in the history and the history itself, is strongly suggestive evidence of a neurological event, and the most likely event would be a TIA (transient ischemic attack). Other possibilities would have to include a sub-arachnoid bleed or brain tumor but the entire episode lasted about one to two hours and then was gone, with no remnant physical findings. At no time did he have a headache so these latter two possible diagnoses would be highly unlikely.
With all this information the patient and his wife were told the physician did not know what had happened. The patient remembers someone saying at some time something about a TIA. The patient was sent home on aspirin (so obviously TIA crossed someone’s mind) and advised re follow up for his blood pressure and that the target BP was 140/90. No other investigation or intervention had been planned other than the respiratory function tests booked for three months later as I previously mentioned.
What was his doctor thinking? Or was he thinking at all? The morbidity and mortality in the first year following a TIA without aggressive intervention is horrendous. When all is considered the working diagnosis in this case is undoubtedly a TIA. This indicates unstable vascular disease and mandates aggressive treatment. At the time he was seen a CT scan of his head should have been considered and at the very least an echocardiogram and bilateral carotid dopplers (ultrasound examination of his carotid arteries in his neck) should have been arranged. His target blood pressure should be 130/80 or less and his LDL cholesterol should be in the basement (less than 2.0). He should be on a large dose of an ACE inhibitor (he is on 5mg. of vasotec---very small dose--- and his blood pressure is 145/90 at home, and he is on no cholesterol lowering drug (it is six weeks after the event). A referral to the Stroke Prevention Clinic should have been put in place.
Again, what was his doctor thinking! Has our preoccupation with cost effectiveness so clouded our judgment that we are putting patient’s lives at risk? Have we forgotten that we as family physicians must first and foremost be advocates for our patients? Perhaps he simply is unaware of the huge financial burden of strokes on society. Perhaps he has not seen enough post-stroke people killed, in wheel chairs, or converted to a “vegetable” state to understand how important it is to grab the opportunity that a TIA offers us as physicians, to make a real difference in a patient’s life-----for better or worse. This was a rare window of opportunity to initiate life saving measures. If something happens to this patient before proper care is initiated and the case appears in a court of law, I will be an expert witness for the plaintiff, not the defense (my usual role) although I truly hope nothing untoward happens (I have informed him of what needs to be done). Our role as physicians is to diagnose and treat appropriately those conditions that can kill and maim our patients. As I’ve said: “What was he thinking”?

Sunday, February 19, 2006

Going For Second Best

Yesterday my blog title was “why primary health care REFORM”? Quite frankly, because the scenario that existed in my practice is rapidly disappearing and access to family doctors and community health care, is finally being perceived as a major health issue. Because the scarcity of family physicians is world wide, a situation aggravated in Canada by various government actions previously discussed, family physicians are able to look at primary care systems around the world and pick and choose where they wish to work. They are also enabled by our system in Canada to look at opportunities that give them more income, in less time, with less responsibility. Young physicians in Canada graduate with high expenses and priorities that include personal and family time. On the other side of the equation, government health administrators see their costs going up and a greater proportion of the population having problems with access to traditional primary care. The increase in “walk-in clinics” reflects the interests of many physicians and addresses the need for “episodic” care but does nothing for the huge need of in depth continuing care and preventative care. Because it is impossible to restore the numbers of family physicians, especially over the short haul (and possibly never), governments around the world are once again resorting to the least expensive worker, working at their maximum potential. Preoperative teams are proving “cost effective” because they facilitate early discharge from hospitals, a major cost savings. They may even facilitate good care. At least in the pilot orthopedic project in Calgary, my understanding is the preoperative team and the post operative team that follow the patient, is the same. But will these principles apply in the community? My experience was the more care givers in the care of a patient, the more tests generated. When public health nurses were doing screening in our schools for scoliosis, I saw many children with anxious parents, usually requesting an x-ray. In the past ten years I spent much of my time with parents of children in Phys. Ed. The Phys. Ed. Teacher suggested the child might need a CT scan. Once an issue is raised, it is very difficult to reject a test that is free. My inclination is that these approaches may end up being more expenses unless some form of rationing is put in place.
All community primary health care organizations and some other approaches such as seen in Great Britain have one thing in common----patient registration. Years ago I disagreed with this concept but I think we have reached the point where this is necessary to address “fidelity” (see previous blogs) issues in the community population. I also feel it is not unreasonable to expect that the public, in return for taxpayer funded health care, should have commitments on their part, including as I’ve suggested before, some form of a screening process on a regular basis for aspects of preventative medicine. From that perspective, Primary Care Health Organizations lend themselves well to aspects of “fidelity”.
In looking at these “team” systems, Canada will have to ask: “What system will attract a group of physicians in short supply and serve the needs of the community?” Various pilot projects have been tried in Alberta. The model that has existed the longest in Calgary is a “capitation” model in which a group of physicians and other primary care providers (using the broad definition) are funded on how many patients are “signed up” with the organization. As one might expect, there have been ongoing “negotiations” between the care givers and the government on funding versus services provided, and I haven’t seen physicians drawn to that scenario. Personally, I do not like this system. Global funding to the Health Care Organization puts the care givers in an obvious conflict of interest. The less money we spend servicing patients, the more money we have left for ourselves! Further, if the Calgary Health Region thought this was the answer I would have expected them to implement this type of community program in their new “South Calgary Health Center” and the new Okotoks Community Health Center.. Instead they operate as glorified walk-in centers. Obviously, the powers that be are still at a loss as to “what to do”.
While they fiddle, other programs have sprung up, some encouraged and endorsed by the Calgary Health Authorities. Some of these programs include physicians, but many do not. My understanding is the Calgary Spinal Program (not sure of the exact name) includes physiotherapists, chiropractors, and other practitioners not covered under the Canada Health Act, as well as specialist physicians. By this inclusion they can claim their charges are not for physician services, thus neatly getting around the Canada Health Act and at the same time indicating that their access to a spinal surgeon (if indicated) would be quicker.
If I were a young family physician today, I would seriously look at practicing in New Zealand. Quite a few years ago the New Zealand government was apparently in a position where they had to make huge cut backs in government funding. One of the areas where they made drastic cuts was to primary care. Since that time there has been an evolution of a primary health care approach that combines government funding, private billing, and “co-funding”. There has been the encouragement of PMO’s (Primary Health Organizations) through “incentive financing” but at the same time recognizing that family physicians are independent Professional Practitioners in health care and as such, have the right to set their fees. They have put in place a scenario that will both service the community and reward physicians for doing the work they are trained to do. As a simple example, the New Zealand Government pays a premium of $26.75 to doctors for visits of patients over 65 years of age. Two years ago our fee schedule in Alberta paid a premium of $1.10 for 75 year and older patient’s visits. Little wonder many family physicians in Alberta have chosen not to look after the elderly----they are far more complex and take much longer per visit. In brief, the New Zealand government co-payments largely support the care of children, the poor, the aged, and the chronically ill (in both health care and pharmacare), leaving the “working class” responsible for their family physicians fees and medications. In this situation there is accountability on the part of the physician to justify their charge based on the service and medications available, and the patient can make a judgment as to whether they received value for their money.
Many aspects of this system still require close examination, but it would appear from the New Zealand Government’s literature they are putting tax-payers money where it should go---- to the care of the poor, chronically ill, and the elderly; while maintaining incentives for physicians to use their training and skills on the population group that will most benefit.

Saturday, February 18, 2006

Why Primary Care Reform

I suppose since the blog site has used the term “primaryhealthcare” it is time I said a few words about what the term “primary Health Care” actually means(this will vary depending who you ask).
Traditionally, this term meant the first “physician” contact a patient made in the community when they required “health care”. “Secondary care” would be those groups of health care providers that the physician deemed where necessary to address the “patient care” issues of that person. “Tertiary care” simply referred to “hospital” care and “long term” care referred to “nursing home” care. This worked very well for me over the years. Over my years of practice I developed a group of care providers that I had confidence in and worked well with. I made it a point to know their strengths and weaknesses, their standard of care and their dedication. In effect this was a team of practitioners (physiotherapists, pharmacists, chiropractors, homeopathic practitioners, surgeons, medical specialist, palliative care nurses, etc) that worked together as a team, a team that I had confidence in, and who had confidence in me. My office nurse was with me in practice for 37 years and knew my patients extremely well and decisions to refer were based on both physical and emotional needs (I even considered referrals based on personalities that would get along). This team of professionals served our community for 37 years, was stable and extremely cost effective. Rarely would a patient be referred for a hip replacement that did not need a hip replacement. Over the years my patients were educated as to when they needed to see me and when they did not, and when they were in doubt, my office nurse in whom they had great trust, gave them appropriate advice. Our practitioner group had a 24/7 call system and over the years we even got to know the other doctors patients. Very few of my patients had under treated high blood pressure or high cholesterol. Obviously, this is a system that needed to be “reformed”!
My patients knew that I was a great believer in preventative measures and basically I think that the patients that were non compliant just got tired of my “nagging” and found some other physician. I was a believer in education AND motivation.
One such patient advised me that she was changing doctors because she was tired of my nagging her about her weight every time she saw me. She had diabetes, high blood pressure, esophageal reflux, and severe arthritis of her back and weight bearing joints. She was also 50 lbs overweight. Eight months later I received a letter from her saying she liked me as her physician and wished to return to my practice (Something I rarely allowed). On this occasion I allowed an interview and invited her in for a chat. I pointed out that it was inappropriate for me to care about her health more than she did and reiterated that weight loss would help all of her ailments. I would take her back only if she lost the weight and I promised that I would not mention it again unless she went over the 10 pound leeway we agreed to. She joined Weight Watchers and lost 45 pounds and experienced considerable improvement in all her symptoms. She also kept the weight off over the next twenty years that I cared for her until my retirement.
Today the public is being sold a new definition of Primary Health Care. Details can be found at www.primaryhealthcare.ca. An incredible amount of money is being poured into various projects under the banner of “primary health care reform”, “primary health care initiatives”, “primary health organizations (PHO---New Zealand), etc. Their definition of primary care is: “basic, every day health care. Primary health care could be visiting the family doctor or nurse practitioner, talking to a dietician or pharmacist, or calling a toll free health advice line to talk to a health professional. It is usually your first encounter with a health care provider when you need care and advice”. What is not said are things like who will be included as “health professionals” and “health providers”, can a patient have free access to all members of the “team”, how is the “team” put together, and who bears the “bottom line” responsibility when things don’t go well. Funding models vary. Interestingly, in Canada “extra billing” has been outlawed. In New Zealand (with their health care reform), they have encouraged it. They don’t call it extra billing, though. Doctors there charge what they wish, and the government pays a portion for the patient as a fee subsidy.
Tomorrow, we will look at the new “vision” of patient care and primary health care reform, and speculate at the reasons for starting down this road. In the mean time a ‘PROMO” of the concept can be found at “www.primaryhealthcare.ca”.

Friday, February 17, 2006

Who Lobbies for Patient Care

Once again, today, Feb17/06, health care demands a prominent position in the Calgary Herald Editorial Page. And once again the “Friends of Medicare” (acknowledged in the article as being an Alberta based lobby group) are mentioned in their opposition to changes in the delivery of health care. Mr. Taft, Alberta Liberal leader lends his voice to opposition, and thrown in for good measure, is the Canadian lobby group for Medicare, the Canadian Health Care Coalition. Michael McBane for the coalition states: “it is very alarming” and “these are very rich and large provinces”.
What strikes me is the fact that I cannot find a lobby group that is speaking out for change in spite of the fact that waiting lists (risk lists) are getting longer and longer while governments are putting more and more of their budget into health care. The Supreme Court of Canada has stated that provincial governments cannot maintain the monopoly on health care if they cannot agree to provide timely access. It contravenes our right to life, liberty, and security of person. Why did it take an individual in Quebec to pursue this issue all the way to the Supreme Court of Canada? One would think that with hundreds of thousands of Canadians in pain and at risk while they wait for interventions, some group within this compassionate society would have taken a position on this issue long before now.
Perhaps it has been the fear mongers such as the “Friends of Medicare” or the Canadian Health Care Coalition who preach doom and gloom and Americanization of our health care system. Perhaps it has been similar action on the part of political parties along with promises and false hope to garner and milk the public for votes. What ever the reasons, there does not seem to be a group that represents all those people on “risk lists”.
Why can’t we hear the thousands of Canadians on “risk lists” screaming “We will not tolerate this anymore!” In other areas of our modern society groups of wronged people are enabled to combine themselves into one entity and bring a “class action suit” against those that have wronged them. I understand there are difficulties in doing this against a government however, should there not be a group in all of Canada who will at least actively lobby for better access for all Albertans and all Canadians and not pander to the system?
There is a factor that may play a part that I have not seen in print, (but my patients have confided it to me) and that is fear. On several occasions over the last few years my patients have felt uncomfortable when I suggested I would push their case with the hospital or the specialist. With more discussion they revealed that if they were perceived as a “problem patient” they may in some way get inferior treatment or be “bumped”. Having experienced this attitude from a few patients, I began asking more patients about how they felt in this regard and it turned out to be quite common. You see, when your life hangs in the balance (and there is only one provider), and a long line up exists waiting for the same service, it is normal to feel insecure and even intimidated. Very few are prepared to speak out under those circumstances. Has our health care system inadvertently become equivalent to a third world tyrant, where punishment befalls those who speak out? Why in many of our health care provider institutions do we have signs that warn patients about adverse behaviors and attitudes? We rarely see these signs in private facilities. Is it possible that we as Canadians have become so intimidated by our monopolistic health care system that we have, individually and collectively, become too fearful to stand up for the choices that European Countries enjoy? Is it possible that we, as a nation, have become as protective of our present health care system as the Middle East is to Islam?

Thursday, February 16, 2006

The Heart of the Matter

It is one thing to NOT put out information to the public that is needed to form rational opinions, but it’s another thing to put out misinformation.
Today on the Dave Rutherford talk show, Dave Havelock stated governments cut back on Medical school enrollment because this was recommended by the medical establishment, namely the Canadian Medical Association. Now, I’m not sure where the CMA came in, but the real reason these cutbacks occurred was the Barer/Stoddard report (that I’ve referred to previously), and that had no medical input of which I am aware. In fact, a good friend of mine who chaired the Alberta Medical Association’s Manpower Studies and their committee at the time, predicted there would be an acute shortage of physicians within ten years and was ignored.
This year’s Health Care in Canada survey suggested that Canadians need a better understanding of “social” factors that affect health. Dr. Gerald Predy, Chief Medical Officer of the Capital Health Region (Edmonton), goes on to say: “there’s an obvious connection between lifestyle and what you eat and your health, but I think they need to have a deeper understanding”. Then he goes on to say: “Reducing income disparities and ensuring as many of our kids as possible will get a good education will probably do as much for health as anything else we can do”. Basically, it would seem, he thinks the socialistic idea of wealth redistribution is the answer. We can excuse him to some degree because he is from Edmonton, BUT, he needs to read my entries “Education versus Motivation”, and “Determinants of Health” entries.. To understanding why there is a relationship between education, poverty, and health we need to look at the determinants of poverty and behaviors that may negate both achieving an education and achieving good health. Does Dr. Gerald Predy really think that transferring wealth from one group in society to another will cause recipients to seek healthy life styles? It sure hasn’t happened with our native population. From what I hear, the winners of large “jack-pots” like the 649 lotto don’t seem to fare so well health-wise.
The Calgary Herald in section E stated that one third of Canadians could not name one “risk factor”. I would suggest that most of these were not familiar with the term “risk factor” which is primarily a medical term. I used to tell my patients that they would score 100% on a health questionnaire and 20% on “do you do these things?”.
Go ahead and try it:
1) Is it better to have high blood pressure or normal blood pressure?
2) Is it better to be over weight or normal weight?
3) Is it better to eat fatty foods or fruit and vegetables?
4) Is it better to be a “couch potato” or exercise regularly?
5) Is it better to smoke or not smoke?
6) Is it better to have high cholesterol or normal cholesterol?
7) If your mom and dad had heart attacks at an early age would you worry about having a heart attack?
8) Is it better to have diabetes or not have diabetes?
Well that takes care of most of them! How did you do? Now, how vigorously do you actually apply your knowledge? The problem of the intro to the article was that it suggested the problem was one of education. Fortunately, it followed this up with some constructive advice. To be truly helpful, we need to come up with the key element----motivation, but that may not be politically correct.
On Valentines Day the Calgary Herald had the heading “Baby boomers face health bust”. The article goes on to say that 58%, in some survey, thought their weight had no effect on their heart health, once again inferring education was the answer. I would suggest this is more a matter of denial. I have on occasion had the opportunity to watch our geriatric “snow birds” at smorgasbords in Las Vegas. Invariably, the most obese have the biggest plates heaped to the brim and go back for seconds including a similar plate of desserts. There seems to be an attitude of “getting my money’s worth”. Believe me, if these people have ever seen any health professional in their adult lifetime, they would have been read the riot act. Perhaps a “free” health care system doesn’t have financial disincentives in place to cause a “second thought process”. It is clear the system I have suggested in a previous blog (To Summarize) with screening every five years with a push in the right direction, and reminders every year, may have a more beneficial effect than preaching to the deaf.
My last beef today has to do with the Friends of Medicare and Alberta’s opposition parties. Ralph Klein’s third way has not yet been released and already they are opposing it. I can see the” Friends of Medicare” (who are not necessarily the friends of good health care) may have some concern over anything that may erode their “idol’s” status. In fact the status quo, with significantly more money into the glorified “Health Care Pot” is certainly a plus for them. But isn’t this about what is good for patients? Various unions are also benefited by more money in the “Medicare” pot and any privatization or free-lancing isn’t to their benefit. Is that possibly why the Liberals and the NDP are also maligning the “third way” before they have even looked at it? Is this a move for the Union vote? I certainly have not seen any solutions they have come up with. And what’s this about people will have to pay health insurance premiums? It seems to me Albertans have been paying them for years and recently Ontario citizens are now doing the same.
As I’ve said in previous blogs: “The greatest problems facing reforming the health care system and making it sustainable and viable are not medical, they are political. Until we put patient interests above those of political parties and special interest groups we are destined to continue down this painful frustrating road.

Wednesday, February 15, 2006

Normal Living Creatures Move to Comfort

It never ceases to amaze me how people who work 35 to 40 hours a week can pass judgment on physicians that work 60 or more hours a week. I had the occasion to sit on some committees that had as members, representatives from the Alberta College of Physicians and Surgeons during my “administrative” years. The committee that particularly stands out in my mind was one that was to look at and outline the health region’s responsibility to the physicians in the region, and the physician’s responsibility to the health region. The position of the college was that “ethical” physicians must provide the region with sufficient “on call” time in all areas, to serve the needs of the public that depended on the region.
So I proposed to this college representative a scenario in which a remote town in Alberta had five family physicians that provided on call services 24/7. One of these physicians dies. Shortly after this, another physician develops a disabling disease and has to retire. This now leaves three physicians looking after the same population that previously was being looked after by five physicians. Subsequently, one of the remaining physicians has a mental breakdown. Should the remaining two physicians still provide the services and care that five had previously? Are they unethical for drawing limits for themselves so that they can perform well? Is the college condoning physicians who are providing services at a time when they are totally exhausted? Are they serving the needs of the patients or the system?
I recall assisting an obstetrician with a caesarean section one morning. He was an excellent surgeon who enjoyed woodworking as a hobby. When he made his incision through the skin of the patient, there was an immediate ooze of blood (usual scenario) which obscured his vision. Before I was able to swab this away, he bent over the incision and attempted to blow it away (with a mask in place on his face) the way a carpenter blows sawdust away from his “marked cut lines”. The nursing staff had not noticed but he knew I had. Fortunately, everything went well with mom and the baby. After the procedure he told me that he had done several surgeries, delivered several babies, and seen an office full of patients in the preceding thirty six hours and was heading home to bed.
What is the college doing to prevent physicians from working when they are exhausted? I would think that the least they should do is support physicians when they restrict themselves to the activities they feel competent doing, and work hours that would maintain their competence.
I recall being at a “Medicare” rally with my seventeen year old daughter many years ago. The guest government speaker spoke out strongly in favor of our system and pointed out that our monopoly system should be credited with many things including doctor’s surgical fees being 1/3 of those in the United States. My 17 year old daughter whispered in my ear: “Yes, but they are missing a great opportunity; they could conscript you and pay even less, or get your services for free by making you slaves”. I was amazed at the insight of one so young when our elected wise “men and woman” (our provincial and federal MLA’s and MP’s), and a room of 100+ adults, didn’t see where things were headed. It was shortly after this event that Canada started to see the migration of our family physicians to the U.S. This migration subsequently cost Canada thousands of doctors and nurses. It wasn’t about the money, either, as many socialists maintain. It was about valuing our freedom and the U.S. valuing us. It was about not being “owned”. Remember, all normal living creatures move to comfort, and most normal living creatures feel more comfortable with freedom.

Tuesday, February 14, 2006

College of Physicians and Surgeons

What a nice piece by Danielle Smith in today’s editorial page of the Calgary Herald supporting family doctors. Other than reporting the shortage of family doctors, it is rare for the news media to turn their attention to the community, I suppose because of the more acute and visible problems in the “acute” sector, (“when your up to your ass in alligators it’s hard to remember you came to drain the swamp” phenomenon).
The College of Physicians and Surgeons of Alberta (CPSA) has always struck me as on unusual organization (that’s probably an understatement). As a profession, we take great pride in the fact that we are “self regulated”. The purpose of the CPSA was to ensure that its members were of the highest quality, conducted themselves as a profession, and provided good quality medicine to the people of Alberta. It has tremendous power over the physicians in Alberta since it is the licensing body and has the authority (through legislation) to grant and take away licenses. It has vulnerability in that it exists by virtue of the provincial government’s approval and therefore some of their rulings could be “tinged” by political expediency.
Curiously, it is totally supported financially by annual fees paid by practicing physicians in the province. In other words, we pay the college to protect the public from us! (a somewhat negative but accurate observation). This frankly, to me, seems weird. We are forced to pay for them financially, but their existence is dependant on government approval. Little wonder at times their positions seem to have political overtones.
When I started practice, the college told us that we could only put two notices in the local paper informing the public that we were opening a practice. It was not to be embellished in any way. We could be listed in the telephone book but not in the Yellow Pages. At that time other health providers such as chiropractors, were advertising in the Yellow pages of the phone book with great framed and attractive ads. They also advertised on radio and television, but this was not allowed by the college for physicians. As a young physician I wondered “did they think advertising was beneath physicians (a form of arrogance), and if they truly believed we were the better health providers, why didn’t they allow us to compete by advertising for the public good”. As years went by, the “old school boys” were slowly replaced by new members (who themselves, by the time they were elected, were “old school boys”) so again their decisions were always at least ten years behind the times.
When the Grace Hospital was sold and the new private owners applied for a license to operate as a private hospital, the province rightly punted the application to the CPSA since it was the mandate of the CPSA to accredit hospitals under 100 beds. Curiously, the CPSA with-held their approval, even though the standards for this private hospital were as high, or higher, than similar small hospitals in the province. Perhaps some political posturing? You think?
A few years ago it was suggested ( a good guess would be the Health Regions of Alberta or some other government related group), that the CPSA investigate the practice of family physicians limiting their practices in both scope and numbers. Fortunately, it is ridiculous to even contemplate that a governing body, responsible for quality care, should tell a self employed worker what they must do, when that worker does not feel qualified or capable. Wouldn’t it be more appropriate for that governing body to look into the possibility that its members are working too hard, since fatigue causes as much impairment as intoxication? To my knowledge that question has not been raised except in residency programs, and I expect it never will be.
Now the CPSA have ruled that Dr. Kim Wilmot and Dr. Jim Mayhew cannot charge for being available. When I was the Calgary District Hospital Group’s Chief of family medicine a few years ago, I received a complaint from the college stating that some of the family physicians in my department (two) did not provide someone to be on call on occasion. At that time, there were 200+ family doctors in my department, most of them doing a wide range of care including obstetrics, hospital care, nursing home care, as well as their community office care. When I informed the college that many walk-in clinic doctors didn’t have someone on call 24 hours a day, I received a one sentence reply: “We don’t get complaints about walk-in clinic doctors not being on call”. So it would seem the more services you offer and the more responsible you are as a family doctor, the more is expected of you, and the more likely you will get at odds with the college. The less the public expects of you, the less likely they are to complain, and the less likely the college will get involved. I spoke to the two family physicians involved in the complaint, and I believe shortly after, they dropped their hospital privileges, a solution for the college, but not for the patients of the two doctors involved.
It would seem that the college has stated that physicians cannot charge for being available. Will that simply lead to family physicians migrating to areas of medicine where it is not necessary to be available? Keep in mind, there is a shortage of family physicians and so there are many options for them.
Besides, provincial governments across Canada have for years been paying physicians for being available. Many of the programs to entice physicians to work in rural communities are flagrant examples of paying physicians to be available. The entire Hospitalist Program in Calgary is an example of the region requiring physicians to be available to care for hospital patients. These physicians have been recruited from communities and graduating classes and are paid far more than community physicians ever were, for looking after hospital patients. How is it that governments and Health Regions can pay for physicians “to be available” but the public doesn’t have the same right? Or, to put it another way, why is it that physicians can be paid by the region for being on call for the Calgary Health Region, but not by their patients. The whole thing smacks of political prejudice on the part of the CPSA. And let’s face it. It is easier to thump on individual doctors when you are the licensing body, than stand up to the government to whom you owe your existence.

Monday, February 13, 2006

Too Little, Too Late

My children tell me that if I was Labor Minister, the unemployment rate would be 0%.
They also tell me that I perceive life only as an opportunity to work, and worry that in my retirement, I will find that life will become “not worth living”. When we took our family drives many years ago they enjoyed teasing me by pointing to the most dilapidated, junky farm and saying: “Hey look, dad, there’s a great fixer-upper place”. They would then cringe when I would show some interest because they knew they would be part of the fixing up project.
Shakespeare said: “There is a tide in the affairs of men, if taken at the flood”. The modern expression for this same principle is “Timing is everything”. The introduction of the “innovative idea” in the last 10 years of using nurse practitioners, physician extenders, cast technicians, etc. is only thirty years too late.
In keeping with my basic personality in the early 1970’s, I had hired a Registered nurse for this very purpose. I spent time teaching her cast application and removal, and how to protect specific areas of the anatomy when applying a cast. She was taught minor suturing, did prenatal check-ups, diet counseling, house calls, and even came to some deliveries as the labor “coach”. Her participation in my practice significantly increased productivity and patient service but there was no way for me to recapture her salary from the services she provided. The fee for service system would not pay for a patient visit or any part there-of unless the patient was seen specifically by me, and the fee schedule never kept up with inflation. I had been one of the Calgary physicians that was doing “extra” billing (deliveries--$50.oo, complete check-ups--$10.oo, routine office visits--$3.oo) but when wage and price control came in, and eventually when “extra billing” became illegal, I no longer could afford the salary burden of two and one half employees and the program was discontinued.
I did not give up without a fight, however. During that time our group had made a proposal to the Alberta Medical Association. I still think it was a do-able proposal, in which the Alberta doctors would opt out of Medicare and do computer billing directly to the patient. The patient then would collect directly from the government. This would put the government in the position of dealing with the patient, who was both the tax payer, the voter and, most importantly, the insured. The patient would always know how much he/she was being charged for the visit and how much the government was paying for that visit. The Alberta Medical Association was in negotiations at that time with the government and had been threatening to back out of Medicare, but when presented with the “ways and means” they not only flinched, they rejected it outright.
It was during this time that another physician and I met with a friend of mine who happened to be the Dean of Medicine at the University of Calgary. We proposed that a certificate program be set up (two to three years depending on the field of medicine) that would train young people out of high school to be “physician extenders” or “assistants”. We, in our group, envisioned having this person to be “office and community procedure oriented and trained", and we could use one in each of our clinics (we had 6-8 physicians per clinic). I was informed subsequently by the Dean that the proposal died because “Nursing” insisted this type of person should go through a 3-4 degree nursing course first. The idea died because of medical politics.
Now this idea is being pushed as though it is going to save our Universal Health Care System. If it could be implemented, it would, of course, make the system more efficient as I had originally advised; however, the timing is wrong. In the 1970’s there was an abundance of young people looking at being health care providers. Now we have a severe shortage of doctors, nurses, and medical technicians. Recruiting from the nursing profession will increase the shortage of nurses and really serves no purpose. Only a small part of a registered nurses training could be applied to what is expected of an office based physician extender. This attitude that a physician’s assistant needs to have advanced training rather than being trained in specific office based procedural things, is counter productive. If a young person out of high school is looking at two alternatives, 1) to be a physicians assistant after a five year post graduate course and 2) be a computer programmer after a two to three year diploma course, with equivalent salaries and benefits, which do you think they will choose. My eldest daughter, six years after taking a two year diploma course in computer programming, had a salary equivalent to mine as a family doctor with 40 years of practice experience.
The fact of the matter is there is incredible competition out there for the bright young minds coming into the work place. The competition is national and international within the health care industry and other industries, and pits all vocations and professions against each other for this young talent. What can the health care industry offer to these young people to entice them? We are failing so far. The idea that there are abundant qualified foreign doctors and other health care workers to fill the void is simply not true. But that’s another blog!

Sunday, February 12, 2006

Who is Your Advocate When You Get Sick?

It has been my experience that in medicine, where a need develops, a service develops shortly after to fill that need. Apparently at one time physicians provided a wide variety of services for patients; manipulation, massage, counseling, and nutritional guidance were only a few of these services. With the advent of microbiology and many scientific discoveries, doctors, as a group became more “scientific” and likely less “humanistic”. Manipulation and the therapeutic value of “the laying on of hands” seemed insignificant compared to the exciting new advances in medicine. Subsequently, because of neglect in this field by medical practitioners, independent practitioners of chiropractics and massage came on the scene. As knowledge in these fields expanded and teaching of these practices in medical schools disappeared, physicians eventually abdicated their place in these areas.
Even in the areas of physical examination and the eliciting of signs and symptoms, the young physicians of today would have trouble competing with the physicians of 70+ years ago. Some of the books that are one hundred or more years old, describe examination techniques and descriptions of signs and symptoms that are incredible in their detail. Today we rely on X-rays, CT Scans, and MRIs. An excellent physical examination will not protect us in a court of law and since a CT scan will, we take the short cut to the CT scan and save time and worry. The end result is the development of, the use of, and the promotion of, technologies that may be marginally better at considerably greater cost, and the loss of our very cost effective clinical skills.
But I digress. The point is that where there is a need, a service will develop to fill that need. Holistic Medicine and naturopathic medicines are some of the fastest growing areas of medicine today. Could it be that our traditional medical system has become so preoccupied with scientifically proven and cost effective aspects of medicine that we have totally forgotten about the human aspect of medicine? Faith, the placebo effect, and the doctor patient relationship (confidence in the provider), may be three of the most cost effective modalities for treating human beings in today’s world of medical science. Yet we in traditional medicine are rapidly moving away from them. Little wonder a plethora of other “private” health care providers are cropping up, giving, for the most part, very personal care and choice. Most midwives’ fee for maternity care is four to five times as high in some parts of Canada as that of an obstetrician. Are they better trained? Absolutely not, but midwives probably give more “personal care” and time, and obviously some people are prepared to pay for this aspect of their care.
The foregoing has simply been a preamble to the point I am about to make. As funding constraints in our tax funded health care system continue, and the system demands more efficiency and cost containment, we will see an ever widening gap in both access to health care resources and access to varying modalities of health care services, between those that must stay in the system and those that can afford to “top off” their care. This is exactly what the original Canada Health Act was meant to avoid.
At present I foresee a huge opportunity for some enterprising physicians and lawyers to set up a private company called “Patient Advocates Inc.”. This company would be hired by patients who have complex medical problems, would review the medical situation presented, review all investigations and reports to date, advise as to what other tests might be advisable, and where the best medical treatment could be obtained, both in and out of the present Canadian Medical system. You see, in a situation that may be a life and death situation, many of us may want to make the judgment of cost effectiveness based on our resources, not on the systems. We will want someone to spend the time with us to go over all possibilities and we will want “involvement” on an ongoing basis. Family doctors served this purpose at one time. Now most family doctors (if you can get one) don’t go to hospitals, don’t do cancer care, and aren’t included often in the “loop” of the care of seriously ill patients in our regional programs. Even if they were, they probably don’t have the time needed to go into the details (they don’t have the time because there aren’t enough of them, and there aren’t enough family doctors for many, many reasons). Let’s face it. Wouldn’t you pay a few hundred dollars to completely understand all the pros and cons of your possible life threatening illness, help you consider all the odds from you’re perspective, and help you develop an approach that you feel comfortable with? Time is a commodity that our present health care provider within the system doesn’t have. Most of us understand that time is money. Physicians outside of “Universal Medicare” will have the time (because they will have control over their lives and practices) and will be able to provide a variety of services.
The system is crumbling. The solution is to focus once again on what Canadian Health Care can and should do: look after the poor, the frail elderly, and the chronically ill. We have the resources to do an excellent job of that; if we allow those that are able to, look after themselves. We can’t be everything to everybody!

Saturday, February 11, 2006


I’m not sure whether I am anti-abortion or simply pro-life, and I realize that immediately some people will say: “they’re the same thing”. As a youngster growing up on a mixed farm in Saskatchewan, I quickly recognized my nature was pro-life. I spent much of my younger years patching up injured birds and animals and marveling at the miracle of birth. On one occasion, when I was 12 years of age, my brother shot a very pregnant skunk. I quickly did a cesarean section and a mother cat that had kittens at the time, happily adopted five newborn baby skunks. I was so protective of life that at one point we had over thirty cats on the farm. My father quickly introduced me to the realities and the economics of farm life.
When I graduated in 1962 abortion was only allowed if the mother’s life was at risk. Most of the teaching pertained to dealing with incomplete abortions (spontaneous, also called miscarriages), and complications there-of. By the time I was doing my residency (internship) I had little exposure to what was going on in the real world, and I’m sure at that time, if I had been asked, I would have spoken out strongly against abortions.
One night when I was working the Emergency department at the Holy Cross Hospital, an ambulance brought in a 23 year old woman (about my age at that time) who was dead on arrival. She lived in Calgary but one week previously had a criminal abortion in Winnipeg. She died by herself in her apartment in Calgary from sepsis, likely too afraid to seek help. I was devastated. Someone with her whole life ahead of her felt she was so alone and without alternatives that she risked and lost her life. I realized from that point on that there had to be a better way.
Though my thinking on the matter had changed, I never did an abortion. I spent an inordinate amount of time in my practice discussing birth control with my young patients, and was seen by my patients (I believe) to be very open with them in these matters. For those that found themselves in a difficult pregnancy position (once abortion was legalized) I spent much time pointing out the pros and cons of all the alternatives. I reassured them of confidentiality and made a second appointment one week later to accept and discuss their position. If they wanted to terminate the pregnancy I referred them to a gynecologist (who did abortions) and any other consultants that I thought would be beneficial.
In honesty, my discussions may have been slightly prejudicial to keeping the pregnancy. It was at times very difficult for me to always accept the reasons given by the patient for wanting an abortion. On one occasion a 38 year old healthy woman with three healthy children at home, once more found herself pregnant. She was obviously quite conflicted since the youngest child was 10 years old and they were looking forward to their life “after the children are grown”. I recall telling her she had the baby-sitters already in-house so she mostly had the next year to deal with!. She went on to have a beautiful healthy baby girl. As this child grew up and eventually married, there was always a strange connection between the two of us.
My issue with the present abortion laws in Canada are that there basically aren’t any. Since 1988 (I believe) this entire matter has been left to medical and authoritarian people on a case by case basis. As such there is no clear National perspective as to where Canada stands on this complex issue. Most countries in the free world have taken the position that a woman does have the right of medical assistance to “evacuate” her uterus. The real question in my mind is does she have the right to terminate the life of the viable (could live outside of the uterus independent of mom) fetus (usually considered at least 24 weeks gestation). This situation is not dealt with in Canada and as a result we have no laws that pertain to some bizarre scenarios. You may recall a woman who isolated the head of her 36 week old baby, still in her abdomen, and shot it through the head. I don’t believe there was a conviction of any kind in that case. A couple could possibly ask for the termination of a pregnancy because an ultrasound showed a lip and cleft palate deformity (easily correctable) in an otherwise healthy seven pound baby intra-uterine baby. Alive or dead, the mother would have to go through some type of labor and delivery. Why not give birth to a live infant and give it up for adoption?
I’m sure that the above scenarios come up very rarely but if we wish to lay claim to being a compassionate and caring society, should we not give consideration to the most vulnerable in our society and work out some compromise with women who rightfully should have final jurisdiction over themselves. The question in my mind is: “Should the right to evacuate ones uterus include the right to terminate the life of a fetus that could survive and be cared for outside of the uterus. Time, I feel must come into the equation, and I believe the woman has a responsibility to her fetus to make a decision in a given period of time. I also believe not making a decision is a decision.
As to abortions before viability, I’m afraid I’ve come to the conclusion that we as a society have simply:
1) Stopped putting significant value on procreation
2) Stopped emphasizing “responsibility” as a positive trait when raising our children
3) Extended our general “throw away attitude”, specifically to fetuses.
The “rights” issue without guidelines and responsibility simply can become an issue of: “I want what I want, when I want it, and you’ve got to give it to me". Like many people, I have come to accept it as something I am prepared to live with although a recent New Zealand study reports that: “Young women having abortions are at heightened risk of later developing mental health problems such as depression, anxiety, and drug and alcohol abuse. Perhaps if there were more discussion on the subject, approaches could be adopted that would benefit the mother and society as a whole.
While we are discussing controversial things; Can anyone tell me why thousands of abortion “by-products” are thrown away in this country every year, when embryonic stem cells supposedly are ideal for doing research that could lead to incredible cures?

Friday, February 10, 2006

On a Personal Note

Every time I drive by my neighbor’s farm, I miss him. He was an old timer that lived just down the road from me and every time I go to town I have to drive by his driveway, so I get to miss him frequently. He was the kind of guy that never said no to a helping hand, seemed to have a broad knowledge of many subjects, but never tried to impose. Coffee was always a quiet and thoughtful time when we just enjoyed time spent together. We shared interests in horses, gardening, and talking about times past.
One day, on my afternoon off, his grandson phoned and told me my neighbor was sick. When I asked for clarification the twelve year old told me: “grandpa is lying on the kitchen floor and can’t get up”. I told him to call “911” and that I would be right over. When I arrived, my neighbor was in shock. By this time probably 10 to 15 minutes had elapsed and he was still lying on the kitchen floor and was semi-conscience. The fire department arrived shortly after I had, and were unable to register a blood pressure. The EMS team arrived some five minutes later, and my friend’s blood pressure was now 40/0 and he was able to answer questions. He had no pain anywhere at this time and it was not clear what the cause of his shock was. It was 1:30 P.M. The ambulance transported him to the hospital after securing an adequate intravenous site.
Knowing that documentation and preliminary assessment would take some time, I followed some 30 minutes later. I spoke to the Emergency Physician and related the history and my examination. On examining my neighbor on this occasion, his blood pressure had improved slightly (was being given copious amounts of I.V. fluids) but he was now complaining of some low back and right abdominal discomfort. It was clear to me at this point that the cause of his episode of shock and persistent low blood pressure, related to something that had or was happening in his abdomen. I again spoke to the Emergency Doctor and related my findings and that I thought the patient should have urgent abdominal imaging. He stated he was ordering an ultrasound of his abdomen. Since the patient seemed once more to be stable, I returned to review the ultrasound about an hour later. Apparently, the patient had again had a precipitous drop in blood pressure, so instead of doing the ultrasound, a C.T. of the abdomen had been ordered by the attending emergency physician, but so far had not been done. My neighbor’s blood pressure was starting to stabilize once again, so I left and came back at 6:00 P.M. I was told that the C.T. Scan machine was down and the patient was now booked for 7:00 P.M. for the scan. Having accomplished little to date, and having no authority over the care being given, I once again left and telephoned the Emergency department at 7:45 P.M. I was informed by the nurse that the patient was on his way by ambulance to another hospital and on follow up, the patient was in surgery at 8:30 P.M. for a ruptured Abdominal Aortic Aneurysm. He survived his surgery but died about a week later from multiple organ failure. One can’t help wondering if the results may have been different if he had been diagnosed six hours earlier. Six hours of shock prior to major surgery isn’t an ideal preoperative scenario!
Not only was I devastated by having lost a good friend and neighbor, but I was more than a little perturbed by the care he had received under the circumstances. Accordingly, I wrote a letter of complaint (as we are supposed to do when we as practitioners see pitfalls in our health care system) to the chairperson of the Regional Quality Assurance Committee (responsible for medical practice standards). My concerns were the following:
1) I felt the Emergency Physician did not take my concerns (and first hand observations) as a professional in medicine, seriously enough.
2) Any type of imaging, in this scenario, including an ultrasound would have been more beneficial than significantly delayed “ideal” imaging.
3) When the ideal imaging modality is not immediately available at one site, a patient should be transferred to a site where it is available.
Four months later I received a reply to my letter. They thanked me for my input but felt the care was appropriate.
At that time in my practice I had given up my hospital privileges; if I had them, I would have taken over the care on the first visit I made to the Emergency department at 2:30 P.M. that afternoon. Would it have made a difference? We will never know. One thing I know for sure, imaging of some kind would have occurred long before 7:30 P.M., and as a consequence, a diagnosis.
What precipitated today’s blog? I read the Calgary Herald Editorial headline this morning: “Better Health Care is the Test”. They were commenting on Dr. Kim Wilmot’s new endeavor. One of the statements in the editorial is: “Surely, any reforms to health care should be designed to improve service for patients, not just help doctors make more money”. Then they go on to say: “The service (referring to the taking on of private patients by Dr Wilmot and providing 24 hour call for a fee) will mean better service for some patients, but its not targeting a trouble spot in the system”.
Doesn’t the Calgary Herald Editorial Board know that all too long we family physicians have been bending over backwards to cope with ever increasing demand, and “trouble spots” in the system? Walk-in clinics were a response to the volume of urgent and minor issues but did nothing for continuing care and long term management of health risk factors. Refusing new patients has and had been an attempt to maintain the quality of care provided to our patients although it meant a decrease in income to those physicians. How long should the medical practitioners be enablers to a system that is progressively deteriorating? The numbers of new graduates that take up family medicine continues to go down for good reason. Perhaps the Herald should examine the reasons.
I have known Doctor Wilmot for all the years of his professional life. He maintained his hospital privileges when most of the family physicians had dropped theirs. He worked as a Hospitalist Physician for years, looking after patients in hospital, that were not his. At the same time he looked after his regular family practice and his special interest “holistic practice”.
I would say he has done his share in trying to keep our “sick” health-care system alive. Dedicating his time to a smaller group of patients is maybe what we all should have done many years ago. So the thought crossed my mind as I drove by my departed friend’s driveway today: “If he had been a private patient of a doctor like Dr. Wilmot back then, would he and I be having our morning coffee this morning and discussing which vegetables and flowers to grow this spring?”

Thursday, February 09, 2006

Determinants of Health

I really don’t mean to horn in on the “whining” domain of my one daughter (www.squiishie.blospot.com) or the domain of my other “idealistic” daughter (lannysblog.blogspot.com) but: Why is it that our “educators” are more interested in promoting their agendas than they are in encouraging the “thought process”? I related, a while back, that I had been to a “philosophers” discussion group on assisted suicide. It was clear that the professor from the U of A was a proponent of assisted suicide and discouraged opinions to the contrary. At the end of the session 95% of attendants supported assisted suicide instead of being impressed with the complexity of the issue and/or requiring time to give it thought.
Yesterday I attended a presentation at the University of Calgary by Dr. David Low, PhD, advisor to the President on public health (formerly with the University of Texas), titled: Does Education Cause Health? It became apparent from the start that this gentleman was a presenter, not to generate thought on the subject, but to formulate conclusions. His first statement “in all populations studied to date, health is not evenly distributed, but follows a gradient which is a function of social and economic advantage”. He followed this with pointing out that in the U.S., where some of the greatest variances in health markers exist, there also exists some of the greatest national variances in wealth.
Now, I agree that there is a correlation between life expectancy and the attainment of education milestones, but is it truly a “function”? (Inferring that there is a cause and effect relationship). He stressed how important the first three years of life was with regards to learning, and was obviously a strong proponent of universal day-care systems with educational components. He made the bold statement in his hand out “The most effective way to improve health of the population is to focus policies on optimizing both early child development and education to provide adequate social and cognitive development in early childhood”. Is this really the “most effective way”? Wouldn’t the effectiveness depend on the policy and the application of the policy? It became apparent as the session continued that Dr. David Low was a supporter of “wealth transfer” as a way of accomplishing this. It would seem that he felt redistributing wealth and taking away “wealth disparity” in a country would make health disparity less. I was astonished that such a simplistic approach would be entertained, much less promoted at this level of discussion.
During question period I asked if perhaps “the determinates of education” could be more important than education itself? Was education just a measure or reflection of personal and local community factors such as: differing values and priorities, conflicting interest (staying alive and putting food on the table may be more important than going to high school), motivation (putting off immediate gratification to attain long term goals, achieving excellence, etc), existing beliefs, (my grandfather felt my going to University was a waste of time and I should clear land and pick stones on a quarter section of land in Saskatchewan), and many other factors. Could these underlying factors that contribute to the attainment of education, in fact, be the same factors that contribute to good health and not education per se? Dr. Low’s response was that my question was an extremely important one but then refused to comment on it other than to say there may be some “third” theory---end of discussion.
I think ideas on health policy are only as good as their planned implementation. Do we take all the children from poor families (families at health risk now and in the future) and make them wards of the state? Do we transfer money for health and education to those groups within our society that have shown their health vulnerability? This has been the policy of our federal governments to date and certainly hasn’t helped our native populations. It seems to be failing on a national scale for the rest of the population as well. How will we ever arrive at solutions when the people who are supposed to stimulate thinking, are advocates for forgone conclusions? I think we should be looking for what constitutes hope in our disadvantaged populations and look at methodologies to address those issues. Hope, to me, will motivate, and motivation in one area spills into secondary areas. We must keep in mind while doing this, that our priorities may not be the priorities of other groups of people (as health care providers we may feel or health values are more important than family or ethnic values). Our willingness to do “good works” for the population at large should never and can never; take away our freedom of choice as an individual.
For better “thinking” on health care issues I would refer you to the following excellent articles: The Break Even Point: “When Medical Advances Are Less Important Than Improving The Fidelity With Which They Are Delivered” (http://www.medscape.com/viewarticle/519943), and “Battling Bad Behavior” (http://www.the-scientist.com/2006/2/1/51/1). These are quite detailed scientific articles for the lay person but for those of you interested in public health policy, they make an excellent “read”.

Wednesday, February 08, 2006

COPD, Euthanasia by Omission

One of the common causes of death in Canada today is C.O.P.D. (emphysema), and although the life expectancy for people with heart disease has been on a dramatic rise, the same cannot be said for people with C.O.P.D. One of the reasons has been that although medical advances have been shown to be a great benefit to cardiac patients, the same cannot be said for medical advances for patients with C.O.P.D. Medications for this group of patients show good symptom relief but really no prolonging of life. Surgical interventions, in select patients, have been helpful, but the numbers helped are a small percentage of the total group. Good nutrition and exercise can have a positive effect, IF the patient quits smoking! In fact, the only thing that consistently and significantly extends the C.O.P.D. patient’s life is the cessation of smoking. This follows, of course, because by far the most common cause of COPD is smoking.
As a society, we will be seeing the impact of this group of people in the years to come, not just from a cost and care perspective, but from a “life expectancy” perspective. Already we are seeing the prominence of smoking in the 40’s/50’s/60’s/70’s and 80’s translated into C.O.P.D. and consequently, pulmonary failure and death. The impact of this group on our health care system of the future may well be much greater than anticipated.
Death occurs because of organ or multiple organ failure. We can prevent death (extend life) by:
1) Preventing deterioration of organs, e.g. reducing cholesterol to prevent heart disease.
2) Assisting organs in their function, e.g. angioplasties on coronary arteries to assist the heart to function.
3) Taking over the function of the organ by some means e.g. organ transplants, dialysis for renal failure, etc.
People die from pulmonary failure when their lungs deteriorate to such a degree that they do not have the capability or the strength to exchange air quickly enough to provide their body with oxygen and to get rid of the accumulating CO2. Lung transplants are done but in an environment of scarcity of donor organs, age basically disqualifies the COPD group. Is there some way that modern technologies can assist the lungs and the patient in gas exchanges? Well, as a matter of fact there is; but it is rarely talked about in a positive way. It is Mechanically Assisted breathing. I had the opportunity to look after someone who was on mechanically assisted breathing and it extended his life by three years. Was it ideal, no, but was the patient quite functional, definitely.
Most people see this situation as being continuously hooked up to a machine, lying in bed all the time. In fact, I think the situation is often “put down” by care givers when they ask the patient “ do you want to be hooked up to a machine all the time and have the machine breath for you?” Actually since the problem is patient fatigue, the machine only has to help you breath and you can have short periods to talk, do your bathroom functions, etc, but it is quite tiring. The machines are quite compact and can be used in your home, the range of movement determined by the length of the electrical cord.
Minimizing effort in other areas is a good idea(walking, moving, etc creates greater oxygen demand) so as time goes on this does become more of a problem. Good nutrition is important to keep up your strength. You can enjoy your children and grand children’s visits and you can correspond through E-Mail and have active internet dialog. You could continue to run your business if you were so inclined. We live in a technical age where entertainment is brought into the home and our homes can be run through your computer. So why are people not choosing this option instead of dying. They certainly would be better off than many people who have strokes and still choose to carry on with their lives. Perhaps in the one to three years that their life is extended a new drug will be discovered that facilitates the transport of gasses though their lungs! The vast majority of these patients simply say they wish to not be “put on a machine,” possibly with little knowledge other than preconceived ideas from television. possibly augmented by frowns and resistance by caregivers. Many of them die in the emergency departments, our hospitals, our long term care facilities, our palliative care units, or in their homes. I’ve often wandered what the information presentation was like to these people and their loved ones. Is cost once again coming into the equation? Are we as health care information providers practicing euthanasia by omission?

Curriculum Vitae

It occurred to me that some readers of my blog may have more than a cursory interest in where my ideas originated. Certainly my years of practice had a profound effect; however, I was also significantly influenced by my experiences while serving on medical committees, and the people and attitudes that I was exposed to on those committees. With this in mind, I thought it may be useful to present my curriculum vitae. For those not interested, “change channels”!
1) Born in Weyburn, Sask., 1938.
2) Grew up on a farm outside of Yellow Grass, Sask.
3) Graduated from Yellow Grass High School, 1956.
4) Graduated from University of Alberta, Edmonton, 1962.
5) Rotating internship at Holy Cross Hospital, Calgary, Alta., 1962 to 1963.
6) Family Practice Medicine Hat, Alta. 1963 to 1967.
7) Family Practice Calgary, Alta., 1967 to Nov.1st, 2003.

Special Medical Committees and Positions

1). 1972 – 1974: Alberta Medical Association/Alberta Nursing Assn. /Alberta Hosp. Liaison Committee.

2). 1972 -1974: Chief of Family Medicine, Holy Cross Hosp., Calgary, Alta.

3). 1970 -1974: Holy Cross Hospital
a) Surgical Committee
b) Psychiatry Committee.
c) Medical Advisory Committee

4). 1974 -1975: Alberta Medical Association
a) Director –Medical Incomes
b) Member of fees Committee
c) Chairperson of Incomes Committee
d) A.M.A. Representative to Canadian Medical Association Incomes Com.

5). 1986 -1987: Rockyview General Hospital
a) Nursing Liaison Committee

6) 1987 -1989: Rockyview General Hospital
a) Chief of Family Medicine
b) Chairperson, Family Practice Committee
c) Medical Executive Committee
d) Quality Risk Management Committee.

7). 1993 -1994: Calgary District Hospital Group (Holy Cross, Rockyview, and C. Belcher Hospitals)
a) Ambulatory Care Committee
b) Head, Department of Family Medicine
c) Credentials Committee
d) Emergency Medicine Committee
e) Chair, Family Medicine Committee
f) Geriatrics Committee
g) Medical Advisory Board
h) Quality Assurance Committee
i) Utilization Management Committee.

8) 1994 – 1995: Calgary District Hospitals Group
a) Head, Department of Family Medicine
b) Deputy Director, Calgary Region, Dept. of Family Medicine
c) Ambulatory Care Committee
d) Credentials Committee
e) Chairperson, Family Medicine Committee
f) Geriatrics Committee
g) Member, Medical Advisory Board
h) Quality Assurance Committee
i) Utilization Management Committee

9). 1995 -1996: Calgary District Hospitals Group
a) Deputy Director, Calgary Region, Dept. of Family Medicine
b) Ambulatory Care Committee
c) Credentials Committee
d) Chairperson, Family Medicine Committee
e) Geriatrics Committee
f) Member Medical Advisory Board
g) Quality Assurance Committee
h) Utilization Committee
i) Founder and Chairperson, Substance abuse Committee
j) Chairperson, Emergency Quick Response Team
k) Chairperson, Community Ambulatory Care Service Committee

10) 1996 -1997: Calgary District Hospitals Group
a. Deputy Director, Calgary Region, Dept. of Family Medicine
b. Ambulatory Care Committee
c. Credentials Committee
d. Chairperson, Family Medicine
e. Geriatrics Committee
f. Member, Medical Advisory Board
g. Quality Assurance Committee
h. Substance Abuse Committee
i. Founder and President, Calgary Regional Family Physicians Association

11) 1997 -1998:
a) President, Calgary Regional Family Physicians Association
b) Deputy Director, Family Medicine, Calgary Region
c) Calgary Regional Bylaws Committee
d) Sub-committee of the Calgary Regional Medical Advisory Committee
1) Physician/Regional Responsibility Committee
2) Taskforce to define the Function and Responsibilities of the Regional Medical Advisory Committee
e) Member of Calgary Regional Medical Staff Association Executive
f) Rockyview Hospital Utilization Project – Physician Advisor
g) Calgary Prostate Cancer Institute – Family Physician Advisor

12) 1997 – 2004:
Consultant to the Law Firm Bennett Jones and Associates on “Community Standards of Care for Family Physicians”.

RESEARCH PAPER 1994: The Family Physician’s Role in Acute Care Treatment Hospitals in Canada

FAMILY PRACTICE MAGAZINE: Article Published Nov. 11, 1996 – Puzzling Over the Prostate

Medical Related Positions Held:

1) Five Years as President of Willow Park Management Co. This was a Management and Medical Real Estate Development Co.
2) Executive Member of Heritage Medical Associates, a Partnership of 15+ Family Physicians.
3) Served three years as Executive Officer of Med Account Associates--- a medical Service Co.

As one can see, I was quite involved during the years of innovation and changes in our health care system. My presence on many committees, I feel, was more for “window dressing” than it was for Family Medicine input. As a result I finally resigned from all committees. Directions often taken were rarely in the best interests of the family physicians or, I feel, the patients. As you can tell, if you have read any of my blogs, cost containment was the primary driver.
My next few blogs will pertain to areas that could be referred to as “Did You Know”

Monday, February 06, 2006

To Summarize

Today I would like to simply summarize the key points that have been put forward over the last few days as a basis for “thinking outside the box”. I will start with the more central fundamental issues.
1) The federal government must take ownership and accountability for the Canada Health Act; after all it is a Federal Parliament Act.
2) There must be an agreement by all levels of government as to what is encompassed by the term “medically necessary” in the Canada Health Act. Without this inclusiveness and exclusiveness, costs cannot be projected or contained. Furthermore, other services that are deemed not to be medically necessary( but possibly have health impacts), can be dealt with through insurance or savings accounts.
3) This agreement could be arrived at by looking at services presently covered by the various provincial governments and dividing them into basic coverage and optional coverage. Basic coverage must be included in “free” coverage provided by all provincial governments; optional coverage could be covered by a provincial government premium system and/or private insurance. Premium subsidies would be provided by provincial governments for low income groups and the chronically ill.
4) A federal body comprised of provincial and federal government health care representatives would review, on a regular basis, those services that should be deemed basic and those that should be deemed optional.
5) Number (4) will be determined by population needs, (not wants), and the government’s ability to meet that need based on federal and provincial GDP and/or transfer payments. Any federal transfer payments must be designated medical, educational, etc so that there is transparency and accountability in federal funding.
6) All Canadians must register provincially for access to the basic health care package as is now the case. The registration would be a more formal process with some basic screening in certain age groups ( blood pressure, BMI, other risk stratification), would occur every five years, would provide information on appropriate resources and referrals, and would have a reminder system in place on an annual basis. Technology makes most of this a pretty simple process. As an example, in Alberta we have moved in that direction with pap. smears.
7) Doors must be opened to private providers. Doctors and other health providers must be allowed to work inside and outside of the publicly funded system. Many highly qualified health providers are working at a fraction of their capacity yet we have long waiting lists. If we can move a surgeon from 10 hours of operating time a week to 20 hours of operating time a week our waiting lists will shrink. Health care workers (nurses, doctors, technicians, etc) will come to Canada because of more options in the work place. If contracting out basic procedures is cost effective, it must be done.
8) Mechanisms for monitoring quality care and assurance must be in place before #7 is allowed.
9) Community teams of providers should be established. Team members should work together on a regular basis. We don’t see professional sports teams working different days with different people on an ongoing basis. There must be a system of authority and accountability of each team within itself and to a representative at a higher regional level.
10) Recognition must be given to general medicine as being most cost effective. Exceptions to the rule is the Calgary Wound Home Care Program and Palliative Home Care Program, but the care of the aging must remain community based, general medicine and general nursing serviced, and specialist referral supported.
11) We must have education programs and organization strategies for the “well” baby boomers and others within our society to encourage them and other volunteers in assisting in the care of the upcoming “unwell” in the wave of baby boomers and chronically ill.
12) Strategies must be adopted to make “people” services more attractive and respected in an age of technology. More visibility of the “good” done, exposure at the school level, more options to involvement, and generally more “perks”, need to be built in to show societal appreciation.
13) Programs must be continued where volume dictates the program to be cost effective and community responsive.
14) Other systems must be set up to help the community care givers deal with the extremely ill and extremely complex patient. A program that sees patients once a month leaves the community to manage this patient for extremely long periods of time. Consultants should be more available until the entire “special team” can consult.
15) Communities and their care givers cannot continue to absorb the discharges from acute care and other institutions into their midst without more tools and resources at their disposal. If we are to use lesser trained personnel (pharmacy assistance, nurse practitioners, physician extenders, etc) we must give them more time to do their duties or more errors will occur (actually true of all of us).
16) Better meaningful communication must exist between various levels of health providers. As an example, the Tom Baker Cancer Clinic has had problems in this regard for many years. Although they faithfully report to the community caregiver each time the patient is seen, the community physician is rarely involved in the ongoing care and decision making. The quick and efficient relaying of results and investigations to the community care giver almost never takes place (all that is needed is “copy to community physician” on the requisition when the investigation is booked), so if the patient comes to us between their visits to the cancer clinic, we do not know what has all occurred and what the results, to date, are. If we aren’t made to feel part of the team, we will exclude ourselves from the team.
17) The development of community transitional care units is imperative. Many patients do not need a full facility hospital to deal with their needs. However, the ability to deal with their needs must be put in place before transfers occur. Without this ability, it is difficult to attract physicians and care givers to the facility and one must question the care the patients will receive. Why can’t x-ray and laboratory space be located in a transitional care facility instead of a shopping center? Isn’t it just as easy for the public to go to this “center” for their tests as to a shopping center? Certainly having these resources on site would enhance transitional patient’s care!
18) A National Drug Plan needs to be initiated, not to cover the exceptionally expensive drugs that are rarely prescribed (that's what insurance is for),but to cover those medications that serve the greatest health needs of the majority of the people (blood pressure and cholesterol medications,immunizations,diabetic medication and supplies, etc.).
The above have been some suggestions on how I think we can make the Canadian Health Care System more responsive to the needs of the Canadian people and more effective overall. Will it be cost effective? I think so (better bang for the buck). Will it be more costly? ----probably. But at least it will be clear as to who bears what responsibility at the government level and there will be more accountability and incentive at the personal level. Comments are welcome.