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?

Sunday, April 30, 2006

Three Cheers For Quebecers

Three cheers for Quebecers! According to a recent Leger Marketing pole, seventy seven percent of the people in Quebec approve physicians working in both the public health care system and in a private system. Whether this is an aberration of Canadian public opinion or is representative of it, is not clear (the article suggests that it is not representative), I certainly take this as a promising sign of better things to come. Quebecers, whether because of more difficult times, a greater sense of fairness, or simply more courage, are prepared to depart from the status quo. A caveat on their approval was that there should be some type of public service Quota that doctors who practice in both systems, are obligated to fill.
On another positive note, 75% of the doctors agreed to the public service requirement of a quota and obligation to the public system. Supporting my convictions that doctors would not abandon the public system, only 5% of physicians surveyed said they would practice exclusively in a private system if one were available; thirty six percent said they would practice exclusively in the public system, and the remainder (a considerable majority), would practice in both and keep up their obligation to the public system.
The survey also found that 81% of Quebecers and 72% of doctors felt that private insurance should be allowed for more procedures than the Quebec Government is thinking of allowing (hip, knee, and cataract surgeries). So thank you, Quebecers, for having the courage to push for change; and a thank you to the Quebec government for taking some definitive steps (although baby steps), in a direction that most politicians, including our Alberta Premier Wannabes, are afraid to take.

Thursday, April 27, 2006

Stanley Cup Health Care? Not Likely

The Stanley Cup playoffs are upon us; and with them the highly priced color men (and women) comment as to who is playing well, who seems “off their game”, what needs to happen to improve scoring productivity, etc. Most of these teams have psychologists to consult if their players aren’t at their “peak”. A friend of mine works part time with Olympic competitors. Movie stars have their own personal trainers, psychiatrists, and lord knows what, because their work is so stressful.
Generally, I think most people would agree that physicians have a stressful job. They probably also would agree that we would like our physicians to be at least as alert and “enthused” about their job as the average entertainer, and if they are a brain surgeon, or a cardiovascular surgeon?------Sorry, I want them to be more on their game than Gretzky, or for that matter, any of the top NHL hockey players, at least if your cutting in my head or in my chest! It is generally agreed that most physicians work more than the 40 hour week. So what kind of “support system” do they have in place? Well, Alberta does have a program that is a “crash watch” system. If you feel suicidal or such, there is a number you can call, and probably jump the queue waiting to see a psychiatrist. Occasionally, some kind folks would put on a “family retreat” where participants would learn how to establish priorities. But ongoing personnel within the system to encourage, support, and make us feel that we are contributing and are appreciated---forget it! My patients were a tremendous help and frequently showed their appreciation. But the system, mostly paints us as the problem. Even Mister Harper recently suggested that if there were a private parallel system all the doctors would stampede in that direction for more money---and would encourage their patients to vacate the public system. Nice picture you painted of us, Mister Prime Minister. Meanwhile, in the U.S., Presidents are often quoted as saying “We have the best and the hardest working physicians in the world”. All too often we Canadian physicians hear from our health “planners”, “if your not part of the solution, your part of the problem”. Unfortunately, others will decide, and have decided, what the solutions will be and what constitutes “contributing”, and we physicians have been, and are, relegated to the sidelines as a “special interest” group.
Recently, on another blog site, I enumerated some terrible examples of bad medical care with correspondingly terrible outcomes. One blogger said: “those are Doctors errors in judgment, and have nothing to do with the system. How naïve can one be? Today, on another blog site, a teacher expressed the concern that most teachers don’t care anymore, and are just going through the motions. I’m still optimistic enough to think that most teachers and physicians (and nurses) still care. Unfortunately, we often feel exhausted from swimming up stream. Everything seems to have to be “negotiated”. We never feel that we are in any kind of control of our lives or our work. And recognition from the public or our “masters” seems to be doled out in tidbits, if at all.
I used to explain to my patients with stress symptoms the following: “Our ability to endure stress is like a bank checking account---you put money in and you take money out. No matter how much money you start with, if you take out more than you put in, month after month, year after year, you will eventually end up being overdrawn and will get a nasty note from your banker. In our day to day lives, we do things, and things happen, that put money into our emotional account to make us feel “good”. Unfortunately, we also do things and things happen, that withdraw from our emotional account----a loved one dying would be a large withdrawal, criticism could be a small withdrawal, but they all add up. Over time it is necessary to balance our books. For those people that care, realizing their efforts are falling far short of their ideal is a significant day to day withdrawal on their emotional bank account. Not getting appropriate recognition for the efforts put in can be a withdrawal. Is it any wonder that one of the coping strategies would be to turn down the “caring” process? (It will decrease the size of the withdrawals) It sometimes has to do with survival.
So it is easy to say “these are human errors and have nothing to do with the system in place, but it is also stupid. When I was working at my peak, one of my darling children (I think she was five at the time) asked my wife if I actually lived in our home. I left for work before the children were up in the morning and got home after they were in bed. They would often bring my meals to my office. (I think she thought I lived in my office). Delivering babies, being on call, business and hospital meetings often took up the week-ends, so she saw me on occasion but almost never in the “domestic” sense. I think it was shortly after that, I quit doing obstetrics. Fortunately, I was blessed with a wonderful wife that was supportive emotionally, and in a very active way in our day to day lives. (actually raised our four children, looked after the finances, the home, etc.----and did a great job). Unfortunately, many physicians’ emotional bank accounts become overdrawn as evidenced by high divorce rates, high suicide rates, and high drug addiction rates. Is there someway of measuring apathy rates or fatigue rates? But never mind, as long as the hockey players have ongoing psychological support so they can perform well. We all know the positive results that winning these playoff hockey games will have on our health and life expectancy!

Monday, April 24, 2006

A Glimmer of Hope?

Although I am swamped with planting, transplanting, fencing, and the usual spring activities on my acreage, it wouldn’t seem right for me not to give “kudos” to Mark Milke for his piece in the Calgary Herald today. Unlike some of the generalities floated about by the opponents of a more open health care system in Canada, Mark Milke actually quoted some statistics and mentioned countries by name that had parallel health care systems. He looked at doctor patient ratios in other countries and it is evident that if Canadian doctors didn’t have a superb work ethic, our risk lists would be much longer and even fewer people would have a family doctor. This actually has been the third article in the Herald over the last three weeks that were supportive of allowing doctors the opportunity to work both in the private and the public system. Perhaps there is a glimmer of hope.
But it is just a glimmer. There is tremendous competition in the world today for well trained physicians, and tremendous competition for young people who have the potential and ability to become physicians. As Mark Milke points out, Canada, at 2.1 physicians per thousand population, has one of the poorest ratios in the industrialized world. As the baby boomers age and begin to significantly impact health care needs, our need for physicians will be impacted more than the countries that already have better manpower ratios than ours. The news media and other people often say the solution is to bring in foreign doctors, but the availability of foreign graduates is becoming non-existent, to say nothing of our problems in this country to insure their capability.
Lanny, at lannysblog.blogspot.com, writes “Shortage of Doctors, no one wants the Job”. She relates that, like in the U.S., where Mexican workers are being brought in to do the jobs that Americans don’t want, Canada is scouring the earth for physicians to come to Canada because we don’t have enough of the home grown variety. A sad state of affairs.
Perhaps we need to ask ourselves that very question; why would anyone want the job? This week I scratched my eye while transplanting Dracaenas. After an hour the eye felt better, but after three hours, it was becoming increasingly painful. Normally, a corneal scratch heals within 24 hours, and certainly shouldn’t be getting worse, so I made my way to a government urgent clinic in my area (it was 9:30PM). The physician there did a thorough exam, identified what appeared to be a scratched cornea, reassured me there was no foreign material in my eye (my major concern), applied antibiotic ointment and put a patch over the eye for comfort. During our conversation he related that he had worked five days in his office (from 9:00Am to 5:30PM) and three evening shifts at the government clinic in the past seven days, easily logging at least 55 hours of fairly intensive work that week.
The next morning my eye was worse so I called an ophthalmologist I knew. He instructed me to come in immediately. It turns out that I had a viral infection of the cornea. The scratch seen on the cornea was actually infected corneal surface tissue. Through the years, we family doctors have been taught that this type of virus leaves a certain pattern and is recognizable by this pattern. Apparently, this pattern is not that common anymore. The more common pattern after a corneal scratch is a transverse abrasive looking bar (like I had the night before). The specialist scraped off the diseased tissue, gave me three prescriptions that I was to get immediately, and advised against patching the eye in the presence of infection.
The purpose of revealing this episode is not to malign in any way the care I received from the initial physician or the government clinic. After all, I am a physician as well and was not aware of this changing pattern of viral disease of the cornea. How does one keep up with these advances? As a retired physician I still receive at least six to eight medical journals a month and probably do more reading now than when I was in practice. How does a family physician keep up in all areas while working 50 to 60 hours a week and perhaps taking a turn on call as well. The major reading we do is in the more vital fields of cardiology, diabetes, and the more life threatening aspects of medicine. All the while, we are berated for not emphasizing preventative medicine in our practices sufficiently, and in one way or another, doing an inadequate job of managing the “health care purse”.
One of the phrases that “burns” me the most in reports and journals is: “The family physician is in an ideal position to-------“. Yes, we are in an ideal position to do most things. The problem is there are fewer and fewer of us, and the knowledge in medicine is expanding at an incredible rate. As we push this group to do more and more with less and less, family physicians will become fewer and fewer.
As I’ve said before: “All normal living creatures move to comfort”. Perhaps Lanny is right in her blog. We have finally created a work environment in the field of medicine where nobody wants the job.

Saturday, April 22, 2006

The Pursuit of Excellence.

At last an article in the Herald that points out something good about the U.S. Health System. In the Editorial “A Healthy Dose of Safety”, it is revealed that there are 50% fewer deaths from preventable medical causes in the U.S. compared to Canada. The credit was given to the impact of malpractice prevalence. The article goes on to describe how frequent medical errors are in hospitals compared to airlines, and then adds the caveat that “it is an apples and oranges comparison.
I must say, the article precipitated considerable consternation on my part that a comparison could even be presumed. Patients entering a hospital are ill, people entering airplanes generally are quite well. Every aspect of a patient in the hospital must be considered; medications, illness and its impact, the hospital facility, etc. Virtually hundreds of decisions and possibilities need to be made and considered, on each patient, each day, while the patient is in hospital. Patients are in the hospitals for days, people are in airplanes for hours. The airline’s main concern is how to get a person from point “A” to point “B” in reasonable comfort and safety. The hospitals main concern is to rescue people from severe illness and manage their recovery. More like comparing apples to elephants, if you ask me!
On the other hand, I have been aware of an increasing “blasé” attitude in Canada pertaining to “good” health care over the years. As practitioners, we are chastised for practicing medicine from a “malpractice” perspective, and even though, as pointed out in the article, significant medical errors in the U.S. are half of what they are in Canada, this type of medical practice is considered to be “not cost effective”.
The U.S. has been using “health care extenders” for many years as a way of reducing cost. The problem with our system using these non-professional extenders is we continually push for increased productivity in a system where there is chronic undersupply of health care providers. To put this in perspective, let us take a scenario where two hockey players are asked to shoot sixty pucks at the open net from the blue line in one minute flat. One of the hockey players is an average guy who has played hockey a lot, but is not a professional. The other hockey player is Wayne Gretzky. Who do you think will miss the net most often? If the average hockey player could take his own time, he would have far fewer misses. In theory, many health extender personnel are quite competent to do the job for which they were trained; but when under stress and asked to continually to speed up their production, accuracy suffers.
For that matter, the same principles apply to professionals. Some ten or so years ago complaints were registered with the College of Physicians and Surgeons of Alberta regarding physicians restricting their practices. It was felt that physicians had a societal obligation to see patients. To me, at the time, this was absurdity, although the College did deliberate on this issue. In my letter to the College, I advised them that their primary concern was for the public, and as such they should more rightfully be assessing those physicians that did not restrict their practices, and should be reviewing physicians who were overextending themselves (to my knowledge, they never have). There is clear evidence that physicians are often so overworked that they are functioning at a level of alcohol impairment. Now compare this scenario to the situation of airline pilots, stewardesses, and air traffic controllers. This group, rather than being pushed to work longer and faster, is rigidly controlled as to consecutive hours they are allowed to work.
When I was part of the administration of the Rockyview Hospital, I put together a program to more effectively track medical errors. At the time, medical records personnel had to go through nurse’s notes and doctor’s notes (after patient discharge) to glean out any problems that may have arisen during the hospital stay. Of course physicians were to make references as well, to “complications” in their discharge summaries. Unfortunately these summaries were often done from memory and often weeks after the patient had left the hospital. I proposed that one specific sheet on each chart should be dedicated to patient complications while in hospital. This could be done as a “formed” work sheet that both doctors and nurses could chart any adverse events. The page would indicate specifically the nature of the adverse event, e.g. secondary to hospital, medication, surgery, disease, idiopathic, etc. The care giver would simply tick off the appropriate box and make a short comment (slipping and breaking a leg in the hallway would be checked under “hospital” and the comment may be “wet floor”). Health records could easily assimilate all adverse events and they could be analyzed and addressed appropriately.
This suggestion was rejected. The reason given was that “charts were already too thick” and the benefits weren’t evident. My conclusion was “if we aren’t aware of what is going on, we don’t need to address it”. More recently, there has, rightfully, been more attention given to errors in our hospitals. But I doubt that there is still a good “tracking system” in place. It would be a “blemish” on the face of our beloved health care system.

Friday, April 21, 2006

Innovation, Canada's "American Inventor"

It must be tough to be a Provincial Health Minister; sort of like a worm on the Canada Health Act hook. No matter how much you wriggle and squirm, there is no getting off of it, so it would seem. Alberta is back to the “innovation” stuff and eight other parts of “the third way” that has been put forward for the past 15 years. The “contentious parts” like doctors practicing in both the private and public sector will be scrapped. After all, apparently Dr. Noseworthy (health Policy division at the University of Calgary) has termed that idea both disastrous and ludicrous. Now, I’m not sure how much medical practice Dr. Noseworthy has actually done, especially in the last 15 years (it would have been nice if the news media had commented on that), but after 40 years of practicing and being actively involved in the “innovation” process, I believe his comments, if accurately quoted, are disastrous and ludicrous.
There is no question that this whole innovation thing started some 15 years ago, and was driven primarily by a shortage of government revenues. Provincial and federal governments were going deeper in dept, and the federal government was being more aggressive in decreasing transfer payments for health and education to the provinces. As mentioned on previous blogs, Baer and Stoddard (with no facts to back them) had come out with a report that labeled physicians as a special interest group, and one of the main causes of escalating health care costs. Provincial governments saw this as an ideal time to bring about “reform” and “innovation”. I remember at the time, calling our premier “Mr. DeKlein”, who ran around crying “The sky is falling, the sky is falling!”. Nevertheless, since that time (at least 15 years), the buzz words in our health care system have been “reform” and “innovation”. Since that time the “at risk lists” and emergency department “wait times” have been steadily increasing (in spite of many committees, focus groups, incentive money, etc); not a ringing endorsement of innovation and reform so far. So what makes us think that another dose of the same medicine is going to do any good?
The original time and place for innovation was completely wrong. If you read the literature on innovation, there are two principle requirements-----an abundance of money and a “buy in” on the part of the participants. This did not exist 15 years ago. The governments were short of money, and since physicians were seen as the enemy, they weren’t about to jump into bed with governments and overhaul a system that they felt was working quite well.
Although I almost never watch “American Inventor” (a new T.V. reality show), I think our Health Ministers in Canada should. There are some valuable lessons to be learned:
First, most every inventor (you can substitute innovator) has made considerable financial and personal sacrifices over a significant period of time, to come to the point of presenting their invention.
Secondly, each inventor believes fervently (like a religion), that their idea is the best in the world and will win the major prize.
Thirdly, the presenters simply cannot and will not be convinced of the fallacies in their “visions”.
And finally, fourthly, an extremely small percentage of the inventions (innovations) are worth considering. Most of the presentations have humor appeal only.
So we will keep going down this road in health care. We will continue to prescribe an antibiotic (innovation) for this viral infection even though we can see the patient continues to worsen. Physicians are now ready for true reform and innovation, the news media is not. The news media seem to thrive more on disasters than successes, physicians on successes rather than disasters. Little wonder we don’t see eye to eye on health matters.
The Alberta government is now at a stage where true innovation could take place. We do have the finances to do some incredible things in health care reform, but we need to have the handcuffs and leg irons of the Canada Health Act removed. Micromanagement and the Canada Health Act have been the jail keepers for the last fifteen years and have called any thinking outside of “jail” and any true innovation, ludicrous and disastrous. Mr. DeKlein eventually had the right idea, but not enough courage and conviction. Unfortunately, Alberta is back to politics as usual, and that means “using health care to get elected” (along with the usual weasel words), instead of being a leader in the field of health care.

Thursday, April 20, 2006

Don't Let Them Escape!

My gut reaction to the Herald’s “Alberta Warned on Health Reforms”, and “Ottawa may cut $1.75 B in Funds”, was “That’s OK, Alberta will cut 2 billion to Ottawa from our Equalization funds. And this all seems to be from the notion that Alberta may allow doctors to work both in the private and in the public systems.
It would indeed take courage to allow that to happen. After all, Dr. Tom Noseworthy, director at the Center for Health and Policy Studies at the University of Calgary, said, “it’s ridiculous” for the provincial government to work both sides of the fence, arguing it would “wreck the fundamentals” of health care. Now he didn’t say what those fundamentals were or how these fundamentals would be wrecked, but I imagine it will be the usual drivel about depleting the care givers in the public system, etc.
Wait a minute, maybe that’s the clue to his saying it would wreck the fundamentals of health care. He knows that physicians, since the advent of Medicare, have fallen way behind most other professionals and tradesmen in the “fee for service” category. He knows that because physicians are locked into a monopoly of a one payer system, the government has absolute control over physician’s fees. For ethical reasons physicians will never go on a full fledged strike (withdrawal of all services). If they did, the government would legislate them back to work in a second, and rightly so. The result is there are never true negotiations; the profession is handicapped by their allegiance to the patient, and the government has the power. History has shown time and again that things would be even worse for us if it were not for the support of the voting public.
So let us take a brief look at whether this is what Dr. Noseworthy meant when he said it would wreck the fundamentals of Medicare. Certainly, in the private system they would no longer have to go through the “mock negotiations” with government. They could look at the fee schedules of other groups and compare---perhaps may even want to do some catching up? Good heavens, the public system will have to compete instead of mandate!
So I thought I would do some checking. I knew that the furnace guy I called a couple of weeks ago charged $90.oo for a 20 minute service. I phoned some large animals veterinarians and they said their fee for a visit to their facility was $67.oo. Small animal veterinarians office visits are around $50.oo. They also informed me that the initial fee is for one problem, so if your horse has a sore foot, a skin condition, and you want to know if she is pregnant, you will be charged for three things (the fee for each varies). If you see your family physician with three complaints, he/she is paid one fee for an office visit. A friend of mine told me recently that he was charged $150.oo (no material) for a visit by a plumber. The visit took 15 minutes of the plumber’s time (my friend lives in a very nice condominium in Calgary, and maybe the plumber had just previously made a “freebee” call on a low income family?).
When I started practice in 1963, I believe a family physician got paid $6.oo for an office visit and $10.oo for a general check-up. I recall having a filling done about that time and was charged $10.oo. Maybe I was given a good deal because I was poor but I think not. Filling a tooth now can set you back $90.oo to $200.oo, a nine to twenty fold increase over the past 44 years. Your family physician will get paid approximately $29.oo for your office visit today, and approximately $60.oo for a complete check-up, representing a five to six fold increase over the last 44 years. A house call by a family doctor pays $64.53, less than a plumber, an electrician, or a veterinarian.
While speaking with a veterinarian, I asked whether they were restricted in what they could charge. The answer was “No, but it is easy to price yourself out of the market”. There seems to be an abundance of veterinarians,----- and dentists,----- and lawyers, but a shortage of physicians in Canada,---strange.
Is it possible that Dr. Noseworthy suspects that doctors will try to escape the financial ravages of a monopolistic health care system that is, and has been “a fundamental” of Medicare? Personally, in spite of all of the above, I have more faith in the medical profession. Those that were looking for more financial remuneration have mostly already left Canada. But it certainly would make the system more accountable as to how they treat their care givers and physicians. And Freedom can be like a pandemic and spread like a prairie fire. Dr. Noseworthy is probably right. The best is to avoid all discussion on the matter, and simply call it “ludicrous”!

Wednesday, April 19, 2006

Strike Three, Over and Out, Thank Heavens

To go on in the booklet “The Bottom Line” attests to my inherent tendency to be masochistic; but I must proceed since I’m at a point of no return. In the interests of brevity (and because the topics seem to be intertwined like the tangle of string I mentioned), I shall deal with the next three topics all at once (sigh of relief).
Myth 3: Private insurance will be cheaper for individuals
The booklets reality: Expanding private insurance is a downloading of costs onto individuals, workers and businesses.
WAKE UP! All this so called innovation over the last fifteen years has been downloading the sick and unfortunate into the community, where their care is virtually invisible and the cost HAS been borne by patients and their loved ones. The system has conscripted the loved ones of the patient, and the community beds (they call it home care), to care for patients that previously were hospitalized. This has forced people to assume a large part of the care, and where possible, try to get insurance for such care (which often is not available). The authors of this booklet acknowledge this huge downloading effect (as do I), and then in a subsequent chapter show that the cost of hospitals, and doctor’s fees has not really increased more than expected, considering inflation and population growth.
Astounding! In Calgary twelve years ago we had 3.3 hospital beds per one thousand population, and 56 long term care beds per one thousand people over the age of 65 years. The last figures that I heard was that Calgary had 1.7 hospital beds per one thousand people, and under 50 long term care beds per thousand people over 65 years of age. No wonder hospital costs haven’t sky rocketed; we have half the number of beds per capita. Doctors fees have only kept up with inflation 10 to eleven times over the last thirty seven years, little wonder doctor’s fees are not responsible for the huge growth in health care costs.
In spite of all this down-loading, the 9% increase in Alberta’s annual spending on health care is not enough (Calgary Health Region was looking for an 11% increase). How do we blame insurance for the above scenario and at the same time say the present Medicare system is sustainable?
An insurance system is designed to pay money for assuming the cost of certain risks. They do not provide care. Their job would be to find a high quality provider in the event of an “incident”, not take on the care of the patient. If we are looking at costs, we must compare “provider costs”. A monopoly has the advantage of having no marketing costs, no competition, and centralized administration. Its disadvantage, financially, is it is heavily unionized. Not only may union workers in health care be paid more, but the union may determine how the workers are utilized (a nurse may not be allowed to porter a patient to the X-ray department). A private facility may have some advantages financially because they are non-unionized, but they need to compete for the patient through service, quality, and reputation. This, advertising, and separate administrations of competing companies, may increase costs. In our clinics, our costs for providing approximately the same services as the Calgary Regions 8th and 8th clinic and South of Anderson Road Clinic, was 50% lower than these clinics. Other private services such as abortions and cataract surgeries are cheaper done in the community because the procedures don’t need the expensive facility (Real Estate and equipment) of a full fledged acute care hospital.
Having an alternative private system may overall, be more expensive, BUT, it will be supported primarily by the wealthiest in our society, not the average tax payer. To make it work, there will need to be availability of private facilities, and there will have to be a benefit for the premium payer. By offering quicker access for elective procedures, we will “unload” our public acute care facilities and free up beds in the public system, resulting in shorter public waiting times without increased “public sector” funding.
The authors claim the fourth myth is that we are moving to a European System. They claim the reality is that we are moving towards an American system. The real truth is the Americans are attempting to introduce a system that is more oriented to looking after people who are incapable of providing their own health care needs; Canada and Europe are looking for ways of providing care for those who are unable to provide their own health care needs, while allowing those who are able, to seek their own and other alternatives. We (and Europe) are moving from being “everything to everybody” (which is usurping our resources and impairing our ability to care for the poor, the chronically ill and the frail elderly) to being “there” for the people within our societies who, for what ever reason, are not able to provide for themselves. The Americans are still on the journey of providing for the poor, the chronically ill, and the frail elderly (many are the 48,000,000 that do not have medical coverage).
The claim that our present health system is “unsustainable”, is put forward as their fifth “Myth”. They go on to show a graph that confirms that hospital costs and physicians costs are reasonable, and therefore the system is sustainable. They do this after spending considerable time in previous chapters and acknowledging that costs have been continuously downloaded on the patient, insurance carriers, and the community resources.
The sixth “myth” that they debunk is that the private system (they seem to want to call it private insurance) will save the public system money. They say the reality is that it may actually cost the public system money. Well, I think we have already gone around that post several times. If we find, through private schemes or programs, sick people, or people that need medical interventions, and these people rightly fall into the category of poor, chronically ill, or frail elderly, then I it may cost the public system more money; that is what we as a just society want from our health care system (as opposed to forcibly providing for the wealthy that can care for themselves).
We have a huge reservoir of medical needs in our society that are not being addressed. Waiting (risk) lists are just the most obvious. Before we can get on with true reform, we need to decide what a medical need is, and whether the intent of Medicare is to control the population (building a health care corral instead of a fence), or develop an atmosphere of, and system for, “choice with compassion”. Strike three, and thank goodness! Over and OUT!

Tuesday, April 18, 2006

Strike Two on the Truth

Chapter two of the booklet “The Bottom Line” is dedicated to debunking the “Myth----Private Insurance will increase access and choice for individuals”. They claim the Reality is: “Private insurance doesn’t increase access”. I gather from much of their material that they do not distinguish between access to the public system and access to private insurance, and they certainly don’t look at a sum total of access. They seem to look only at access to “insurance”. They quote international figures that show that wealthy people are more likely to have private insurance than poor people. Duh! They say people with chronic illnesses are not insurable. Duh! As long as the government keeps up the funding for the public system, diverting people to a differently funded system will work, just do it right.
Perhaps we need to review once again why the taxpayers support a publicly funded health care system ----- to provide medically necessary care for the poor and chronically ill. The authors quote a case where a patient was turned down for private insurance because her parents had cancer. My suggestion is that the patient should have shopped around. At age 60 I got the best rate of life insurance available for that age group, locked in for ten years, and not only did my parents die of cancer, but my sister died of cancer at age 47 and my brother at age 52. I grant that in order to have competition in the insurance industry, the system has to offer more than dribbles of business. There has to be sufficient competition to have competitive bidding by a number of providers.
The authors mention that even with government subsidies to Blue Cross, some patients with chronic illnesses cannot afford the premiums. I agree. If you have read my previous suggestions, I have suggested a National Pharmacy plan, federally funded. Remember, the idea is to care for the chronically ill! Insurance should be for; “The possibility of a health event that may be costly”. If people have a KNOWN illness, we as a society have an obligation to provide a safety net for them. I don’t want insurance companies to be health care providers; I want them to be “Insurance” Companies. For there to be a demand for their policies, however, there must be a reason for someone to pay more, and the job of the insurance company is to provide options for the insured in the event of unexpected negative health situations.
Unfortunately, it would seem that some people think those who pay premiums should not get anything in return.
Let us take a wage earner who makes $100,000.oo annually and pays $30,000.oo annually in taxes. He already is supporting the public system more than a taxpayer who is paying $10,000.oo annually. He waits in a medical “risk” line like everyone else in our public system. This is how our society functions at present, right or wrong. What bothers me is not that scenario, it is the people that feel that even if the taxpayer were to pay $10,000.oo in premiums a year in addition to his $30,000.oo tax bill, he should not realize any benefit (queue jump), even for elective surgery (Socialist thinking is he should pay $10,000.oo more in taxes because the government knows how to make sure the dollar is well spent better than he does). Taking this person out of the public system provides an additional space in the public system; therefore it is a win/win situation.
For a subtitle that uses the word “truth”, the authors do their best to avoid it. “Prior to 1961”, they state, “only 53% of Canadians were covered by health insurance, leaving approximately eight million Canadians without coverage”. Well, I really don’t know about other provinces in Canada or what the authors mean by health insurance, but when I started practice in Medicine Hat, Alberta, in June, 1963, all patients were covered for Hospital and cancer care. Further, 90% of patients were covered for doctor’s fees. Medical Services Incorporated (MSI) was the main carrier (a non profit carrier) but there were many others. Nowhere is Alberta’s success or MSI mentioned so far in their booklet.
The authors contend a parallel private system does not reduce wait times for the following reasons:
1) Private insurers can afford to pay care givers more and therefore care givers move to the private system.
Why can private insurers afford to pay more? They have advertising costs and higher administrative costs as pointed out by the authors. The TRUTH is the public system CHOOSES to pay less. And they have done that effectively (as pointed out by the authors) in our monopolistic system because they CAN; so much so that there is a world shortage of most health professionals. Strange, there is no shortage of dentists, veterinarians, or lawyers.
2) They say that premiums are not open to public scrutiny.
They must mean government scrutiny. Surely the person paying the premium would be aware of the benefits. If the consumer feels he is getting value for the money, then “scrutinizing” the company books isn’t necessary.
3) They claim doctors going to the private system won’t take their patient load with them.
The easy solution for surgeons (they are the ones with long risk lists) is to simply keep their allotted operating room schedules in place. Their private work would be in addition to their public work. In many cases this would add 40% to their productivity.
4) Those with higher health needs will be left in the public system.
Duh! Remember, the public system is “supposed” to look after the chronically ill (higher health needs).
I would contend that if a parallel system is not lowering the wait lists, the system has been poorly devised and implemented. The bottom line is increasing a surgeons productivity from 60% to 100% will have an impact on “risk” time. Strike two on Diana Gibson and Colleen Fuller.

Addendum: Danielle Smith has a good article on this subject in today’s Herald Editorial Page. She quotes countries and stats that show parallel systems can shorten wait times.

Monday, April 17, 2006

Debunking, Strike One

Have you ever tried to untangle a real mess of string or rope that is hopelessly intertwined? I kind of feel like that when I’m reading the booklet, “The Bottom Line”. You take a piece of the string and follow it to see were it goes (in the hopes of teasing it out to an end) and it disappears in a whole lump of other parts of the ball of string. One is tempted to cut off each small piece of string that one can isolate and then try to tie each small piece together, but that would be a horrendous job, and at the end of it you probably would be left with nothing useful. Or maybe in exasperation, throw the whole thing in the garbage. But I promised to look at all aspects of this health-care thing, so here goes, we have to start somewhere.
One of the things that is disconcerting in this booklet, is the tendency to put forward opinions that are controversial, as though they are facts (I note the subtitle of the booklet is “The truth behind private insurance in Canada”). Throughout the book, quotations are taken from people who had bad experiences financially, prior to Medicare, in the health care field. These quotations date back to the nineteen thirties and forties, and many of them from Quebec and Ontario. No one said things were perfect then, but I know that supporters of the present system cry foul (for good reason) when the news media present “the disaster of the day” in our present system. Intelligent discussion cannot come about by citing case scenarios for affect. We can look at each case and learn from it, but deliberately creating a negative attitude is self serving. Testimonials do not facts make!
In the introduction, Shirley Douglas (not entirely impartial) is quoted as saying “You either want a single payer system in this country, or you want an American style system. And don’t kid yourself that there’s anything in between”. Well, in fact, everything else is in between. Canada and Cuba are the only two Health Care systems that have a “One payer System” (possibly also North Korea). The U.S. has 48,000,000 people without health care coverage (about 20% of the population). Are there any industrialized nations of the world that don’t fall between these extremes?
Gillian Steward is quoted as saying:” Medicare is as Canadian as hockey or Mackintosh apples”. Does this imply that Canada was the first or only country to bring in a one payer system? Or are they implying that, it in some way, with its thirty seven year history, Medicare is part of our Canadian Heritage? What is the relevance from a rational perspective?
The authors claim their main thrust is to debunk some myths with hard reality. In doing this, the first myth they debunk is “Private insurance is a “new” model for health care”. Is there really anyone that puts that idea forward or uses it as an argument? I certainly never have! This is like saying “They said two and two is five, when no-one ever said that”, just to discredit the opposition. They say the reality is: “Albertans and Canadians have already experimented with, and rejected private insurance and for-profit delivery in favor of the universal public single-payer system. No, the reality is that Canadians, especially Albertans, were bribed by the federal government to abandon their previous well functioning system, and experimented with the new proposed universal public single payer system. Most of my patients in 1969 could not understand why the system was being changed. I had to explain to them that the Alberta government stood to gain 50% of the cost of provincial health care from the federal government if they joined Medicare. The authors point this out in a subsequent chapter so why cloud the issue? The opposition parties and main stream news media railed against Premier Ernest Manning in the 1960s for even contemplating foregoing this federal windfall, as the authors point out in their booklet. The truth of the matter was many of the European countries, including England, had already gone down the “one payer system” road and lost many physicians to Canada as a result of it. It was however, a “vote getter”, and popular with Unions (government’s programs and personnel, are highly Unionized), and politicians are always looking for votes. As Canada was attempting to embrace this “new” Medicare experiment thirty seven years ago, the European countries began contemplating ways and means of extracting themselves (as we are now), because they were finding the costs escalating beyond their expectations (as we are now). Strike one on “debunking”!

Saturday, April 15, 2006

Truth and Consequences

I think I related this experience in a previous blog but in view of the booklet I am reading, it needs repeating.
Approximately twenty years ago I went to Washington to see an Arabian horse that was advertised for sale. She was a daughter of Bask, one of the leading sires in the Arabian horse industry. When I arrived the mare was brought out for my inspection (She was well groomed and well presented). Part of assessing a horse is to observe the animal in motion, so accordingly, I asked the owner to trot the horse away from me, and then towards me. This process confirmed to me that this mare had the worst back legs that I had seen on a horse in a long time. She was so close behind that she almost hit her back legs together as she moved. I asked to see some offspring, and sure enough, her offspring unfortunately had the same terrible back legs. Now, there was no question that this was a beautiful Arabian mare, well put together in other ways, and had an excellent pedigree. During the showing of this mare, the owner said nothing, he simply watched me looking at the horse. After a considerable time, he approached me, put an arm on my shoulders in an endearing and confidential way, and said: “You know what I like about this horse, doc”? I said “Tell me”. “I think this mare has incredible back legs”, he said. “Absolutely incredible”, he said.
I was dumbfounded. First I looked to see if he was joking. Then I looked once more at the horses back legs and then at the owner again. I’m sure my expressions were bizarre. Needless to say, I didn’t purchase the horse. It occurred to me later that the good aspect of the horse were apparent. It likely was obvious to the owner that I had concerns about the horses back legs. In order to sell me the horse he would have to allay my concern about the fault, and the best way to do that would be to make me doubt my own judgment. If I perceived the worst trait of this animal was its back legs and he thought that was the mare’s best trait, then perhaps it wasn’t as bad as I thought. From that day on I realized that when someone wants to sell you something, they will often take the weakest position on a subject and present it as the strongest argument for a position. The same principle applies to issues in health care. If the major claim to changing from a monopolistic tax payer funded health care system is that it is unsustainable, then the advocates of the status quo are going to make a huge point that the present system is by far the most affordable and cost effective. Most of us can see the things we like about our health care system, what concerns governments is the large chunk health care takes out of the provincial budget, with the ever rising cost. What concerns us, the consumers of health care, is the increasing lack of accessibility, with the associated long “risk” lists. If the person making the pitch takes the negative and totally misrepresents it as a positive, we may then go along with their position. Similarly, if they take the positive and blatantly and deliberately misrepresent it as a negative, they may have taken away other options. This may require a certain amount of crass and dishonesty, but there seems to be a lot of that going around lately.
Over the last twenty years I have always kept my Arabian horse experience in mind when I sat on committees dealing with health care reform. When the government said we are going to make health care “patient focused” I groaned, knowing that we would be moving towards “management and cost effectiveness focused health care” and away from being “patient focused”. Recently, I once again was reminded of my previous horse experience when I read the title to a book titled “The Bottom Line” (The truth behind private health insurance in Canada). When someone claims to expound the “truth” about anything in the health care field, I flash back to the best thing about that horse was “its back legs”. This book sounds like it is trying to sell me something.
I shall read it over carefully and decide for myself. I note that neither of the authors are physicians. Diana Gibson has a background in public policy and has affiliations with the Trade Union Research Bureau. Colleen Fuller is the president and co-founder of Pharmawatch, a consumer advocacy group. It will be interesting to read what these two non-medical/non-physician advocates have to say. Stay tuned as I read their version of the “truth”!

Thursday, April 13, 2006

Iris Evans, Minister of Health and Wellness, Nice, but-----?

Yesterday I received a very nice letter from Iris Evans, Alberta’s
“Minister of Health and Wellness”. On previous blogs, I have advocated a provincial program whereby on their 40th birthday, Albertans would get a notice from the government suggesting that they see a health professional and have a basic assessment as to risk for cardiovascular disease and diabetes, and this should be done every five years (not unlike notices seniors get at age 75). I pointed out that statistics show that 65 to 70 % of people do not know they have high blood pressure or are inadequately treated. Similarly, 65 to 70 % of people with cholesterol levels that need intervention are not being attended to. I pointed out the cost effectiveness of such a program in preventing strokes, heart attacks and all the complications of diabetes. The screening would basically be very simple and not need a health professional to administer. Blood pressure, waist circumference, BMI, and family history would be the key, with blood work done on those with two of the four risk factors mentioned above. Patients at risk would be referred for intervention as required and given appropriate medical information. This program idea and its rational, was sent to our Health Minister, Iris Evans.
Childhood immunization and influenza immunization in the chronically ill and elderly have proved to be one of the most cost effective things we do in medicine today. The news media repeatedly reports the “epidemic” of obesity in the world today, especially in the U.S. and Canada. Interestingly, Dr. A Tremblay, Professor in the Department of Social and Preventative Medicine at Laval University, reported in a paper published in Nov./2000, that the papers and scientific research published on obesity have been increasing over the last twenty years at the same rate that obesity has been escalating unabated. In other words, we talk about it, but nothing is being done about it. The increasing incidence of diabetes in the world follows the same increase as obesity, only ten years later. There is no doubt as to a cause and effect relationship.
It is suggested that a one point drop in blood pressure of Canadians could translate to 480 fewer deaths from stroke per year, 1,580 fewer deaths from heart attacks, and possibly hundreds fewer cases of vascular dementia. If we screened for those people at risk, and effectively intervened, the impact would be incredible.
So let us look at Iris Evan’s (Minister of Health and Wellness) reply. She states:
“There is no doubt that the indicators you have outlined are key factors related to an individual’s health status and potential risk for developing certain chronic diseases. This type of preventative care should be provided as a component of an individual’s ongoing, routine care where a strong patient-physician relationship is a fundamental component”.
Iris, you’re not paying attention! The point is---it’s not happening, for many reasons, not the least of which there are fewer and fewer family physicians, and walk in clinics provide primarily “episodic” care, not continuing and preventative care.
She then goes on to do the sales pitch thing: “Alberta is in the process of implementing a number of province-wide initiatives that will support and facilitate the above. ( I think she is referring to the doctor-patient relationship). For example, a key goal of the Primary Care Initiative is to increase the focus on health promotion and disease prevention in the care of the patients at risk for chronic illnesses”. Now, I’ve been hearing that for twenty years, and as Dr. Tremblay reports, we talk more about it, but what do we DO about it. The key issue is: “How do we pick up those people at risk early on in the disease process and spend our money in a cost effective way with the people that will benefit the most”? That is what my suggested program is all about---fidelity---getting the right treatment to the right patient at the right time. We have all this great medical knowledge, but are severely handicapped because of access problems to the people that would most benefit. We generisize and generalize our message to the population at large instead of targeting an at risk age group----40 year olds and up. We don’t do that with childhood immunization, seniors flu shots, or drivers exams, why are we ignoring an at risk age group that are in their most productive years of life.
Iris Evans, our Health and Wellness Minister, finished her letter with: “The Government of Alberta is strongly committed to disease prevention and early detection as a key strategy in health renewal and reform. I appreciate your interest in health promotion and prevention for Albertans. Thank you for writing”.
It was a nice letter. I kind of felt like our kids must have felt when they had an issue and we as parents would take the “there, there, you’ll feel better in the morning attitude”. But she did respond, and she was nice----but mostly platitudes, no analysis of the program I proposed, and nothing new on the Government’s part. Guess it’s time to get back into my gardening. At least there, my efforts bear some fruit.

Wednesday, April 12, 2006

Care Brokers, An NDP Necessary Evil

In the Nov/05 issue of the National Review of Medicine Newspaper, Jean Crowder, the Health Critic for the Federal NDP, is quoted as saying: “What it does point to is a need to take a look at what’s wrong with our public health care in this country. The question is, why are we putting people in the position that they have to use them?”
What she was referring to as “them” are care brokers. Now some of you have not heard of care brokers but they have been around and active for at least the last twenty years. Like an insurance or mortgage broker, they will find you whatever medical service you wish----OUTSIDE of our Universal health care system (unlike the insurance and mortgage brokers, what they find for you may be a matter of life or death). So it would seem that although the NDP are adamantly opposed to doctors working in both the private and public systems, Ms. Crowder (according to the article), sees these brokers as a necessary evil in a health care system as overwhelmed as Canada’s.
Now I have never heard any of the political parties outline the solutions to our health care dilemma. Yes, I know, innovation, increasing efficiencies, technology, etc; I’ve heard them all for the last 15 to 20 years, while waiting times (risk times) have grown longer and health care providers have become a scarce resource. Annual increases in health care spending routinely exceed our GDP, and in today’s Calgary Herald, Jack Davis, Calgary Health Region’s C.E.O. states health care needs a further major infusion of money. It would seem this province’s 9+% increases annually won’t do the job. Can anybody say “not sustainable?”
So let us look at this care brokering business that Ms. Crowder states is “a necessary evil”. They will find you medical services if you wish, and, if you can afford to “jump”, one of our many queues. If the best price you are quoted exceeds the price they can find for you, they will take a percentage of the money you have saved. So if a surgery is proposed to you by the Mayo Clinic at a price of $40,000.oo and they find a place that will do the same procedure for $30,000.oo you have saved $10,000.oo minus their commission. In this scenario, it seems to me, the incentive for the “care broker” is to find the cheapest price, not the best place. That insures them of the largest commission.
The article states that these brokers (in B.C. and Montreal) are doing an ever increasing booming business. And the NDP health critic considers this conflict of interest a “necessary evil”.
Recently, in Mr. Harper’s letter to Mr. Klein, Mr. Harper felt that if physicians were to work in both systems, they would be in a conflict of interest. For some reason (he suggested financial), physicians would encourage their patients to access the private system instead of using the public system. I have news for Mr. Harper and any other similar thinking politicians, we are already doing it and have been for years; and it has nothing to do with remuneration, it has to do with acting in the patient’s best interest.
If I had a patient that I felt needed surgical intervention for a disc protrusion/extrusion, I would suggest that the patient get a private MRI. This could be done within two days in the private system and two to three months in the public system. Without the MRI result included with my referral to the Neurosurgeon, the neurosurgical consultation may take months and the surgeon would still have to wait to make a decision pending the public MRI. With the MRI enclosed with my referral, the surgeon could better assess the urgency of the situation. The result was the patient was seen and operated on more quickly because he/she needed to be operated on more quickly than the system allowed (but effectively queue jumped). Doing this did not put a penny in my pocket, but it helped me sleep better at night knowing I had done what I could for my patient. This type of activity by the medical profession facilitates queue jumping and could be called a “necessary evil” in a health system as overwhelmed as Canada’s.
But let’s consider the “care broker” scenario. They will arrange to get the private service faster but their revenue is directly proportional to how cheap it can be done. The incentive is to find the “cheapest” care, not the “best” care. In fact the “best” care may not provide any commission. This is conflict of interest at its worst, and possibly a detriment to the patient. Where are our governing bodies? At least a flat fee for finding a private provider may include concern about quality care and risk management without financial disincentive.
The whole system sounds a little bit like: “hey, Mister, you wanna buy a watch?” or in Cuba where if you need something the response is “I no got, but I gotta friend” or in Soviet Russia where the “blatnoi” (fixers) would look to the needs of the politically well connected. But what does one expect from a monopolistic socialist system that would brand all its doctors as being enemies of the state, who would flee to the private system for financial gain. From where I sit and from what I’ve seen, most of us practicing physicians use the private system through concern for our patients and their safety. If only the same attitude prevailed for the die-hard supporters of the system.

Saturday, April 08, 2006

Alberta's Pathetic Leadership Hopefulls

It really is pathetic. The Alberta provincial conservative premier “wannabes” are taking exactly the same approach as the federal politicians have during the last four elections. The greatest phony would seem to be Jim Dinning. As provincial finance minister, he cut health spending and services and started the problems in our public health care system in Alberta. He was the big “Poo-Bah” of the Calgary regional Health Authority for several years (and during that time was always over budget and going to the provincial government for more money). He, of all people knows first hand the present system is not sustainable. Yet, he has the unmitigated gall to declare that he will be the guardian of the present health care system, and will squelch any aspect of the “third way” that will come in conflict with the Canada Health Act. Sounds exactly like Mr. Paul Martin and Mr. Chrétien before him, and for that matter, Mr. Harper in the last election. It would seem that the best thing to do as a politician is keep the Medicare system in a state of crises, and declare before each and every election that you are going to “fix” it. Quite frankly, it makes me sick, no pun intended.
Let us review once again some of the issues:
1) Some people say that waiting times for cataracts have not gotten shorter since they have been moved to the community and out of the hospitals and therefore “private clinics” won’t shorten waiting lists. Perhaps what they don’t know, or don’t want to know, is that the Region will only agree to contract out a certain number of cataract surgeries per year. So if 1000 cataract surgeries will be needed in 2006, and the region only agrees to contract out 750, then it follows that 250 people will be put on a waiting list. After two years, there will be 500 people on a waiting list, and so on. New ophthalmologists coming to town won’t help the problem because the region only contracts out a fixed number of cataracts, always less than the needed number, to save money.
2) Orthopedic surgeons in the Calgary Area are not working to capacity. This is because they are limited to a certain number of hours of operating room time. This is necessary, not only because there are limited hours available in our operating rooms, but there also are limited beds to put patients in after they have been operated on. Contracting out surgeries will only help if the number of surgeries in total for a year equals the demand for that year. As with cataracts, contracting out procedures costs money and money can be saved by building up a waiting list. It’s that simple.
3) Has anyone actually seen the exact process that has been put forward in orthopedics as being the salvation of hip and knee replacement surgeries? My understanding is some money can be saved by stream lining the procedures preoperatively, operatively, and postoperatively, and that seems reasonable. But what I understand is that this is a pilot project (in other words this is being done on a small scale in a specific area), and I have heard that in excess of twenty million dollars was put into the project to “kick start it”, and a similar amount of money has been granted for its continuation for the next year. I certainly have not seen a cost accounting of the procedures done, the age of the patients, their risk status, etc. If this small pilot project requires 20,000,000.oo dollars a year to operate, how many hundreds of millions of dollars are required to apply this one orthopedic program to the entire province and what is the cost, and the cost savings. Further, can the public system afford to do this? From what I can see this is tinkering, and not a solution. The bottom line is it will require billions of dollars to shorten wait times (risk times) in our health care systems and politicians don’t want to take the money from other priorities. So they fiddle (they call it innovation for the last twelve years) and lie to the public.
4) Guaranteed wait times sound good, but will be an administrative nightmare. What are you going to do if your wait time extends beyond the recommended wait time, sue the government? Sounds like a “make work project for the legal profession.
5) The wait times recommended by the C.M.A. and others that I have heard are attempts to entice the governments to move forward on this issue, but have no bearing on the medical facts, that I can tell. The recommended wait (risk) time suggested for a patient with a fractured hip to wait before having surgery is given at 48 hours. In the last year, an excellent article was published clearly showing increased morbidity and mortality in this group of patients if they wait longer than 24 hours to have their hip repaired. So where did this 48 hour figure come from? I suspect the other wait times similarly are not backed by medical evidence.
6) Doctors, particularly surgeons, MUST be allowed to work in both the public and private health care systems. At present, some orthopedic surgeons are working at 60% capacity in the public system. What would we think of a company that had millions of dollars of expensive equipment standing idle 40% of the time, but was not meeting the demand of their customers? Probably we would suggest it deserved to go out of business. Frankly, forcing physicians to work in one sector or the other is micromanagement and just plain stupid.
Why in heavens name do we keep voting in the politicians who know the state of health care in Canada, and basically guarantee the status quo? Where is our indignation? Where is our courage? And perhaps more to the point, are there no leaders with the courage to come out, say what the situation is, and have the courage to do something about it? Klein talked the talk, but was afraid to walk the walk. Our new “wannabes” are even afraid to talk the talk.

Friday, April 07, 2006

Health Regions, Container Gardeners

The Provincial Department of Health and the Regional Health Authorities could never be gardeners. This thought occurred to me today as I was doing a bit of spring clean up and transplanting some seedlings.
It has always amazed me how, we as gardeners, have our own ideas about gardening as novices (even with, and maybe because of, all the books we read in the beginning), but after many years, we find out that Mother Nature and all the varieties of plants we work with, have her and their own ideas. As I have worked on this property over the years, various annuals that I planted originally in one place, have decided to become “native” and come up voluntarily with no help from me, in a totally different area. Surprisingly, the number of plants that I need to start each year has decreased significantly as each variety has found its niche in my yard, requiring less support from me in weeding, fertilizing, watering, pruning, and planting. I don’t even have to buy the seeds. My wife swears that I wouldn’t have to even start plants anymore, perhaps just do a bit of thinning in areas of overabundance.
I, of course, like our governments and health regions, still feel that I need to control everything. Fortunately, over the years, I’m slowly learning the lesson that our health bureaucracy has not: Everything does not have to be micromanaged. In fact, masterful inactivity, allowing each plant the opportunity to establish itself where it thrives naturally, seems to work best. As a gardener, the best thing I did was to give each plant the opportunity and a variety of options, and over a few seasons, my yard has become a mosaic of colorful, happy vegetation.
So now, to express my need for control, I do quite a bit of container gardening. I probably have about fifty hanging baskets and pots of various shapes, sizes and colors. For each pot I carefully pick out the type of soil, the fertilizer, the plant material, and the location of each container. Then I spend all summer running around watering and fertilizing the pots. If I want to take a few days off in the summer, I have to hire someone to water my container plants while the rest of the yard looks great and could care less about my presence or absence. Furthermore, my choice of plant material and location of pots just doesn’t turn out so well on occasion, and many of the varieties that thrive in the yard, just die in the containers. But I’m slowly learning; It would seem everything on God’s earth moves to where it is comfortable. We humans should focus more on facilitating. I would think that in any situation, the more options, the more likely comfort will be found.
So I have concluded that our administrators and legislators of the health care system are container gardeners at best, and not good ones at that. They are big on elaborate containers, trying to put the care givers they want into those containers and then put administrative micromanagement in place to ensure survival of the “arrangement”. Unfortunately, as they have found out over the years, this is costly and there has been increasing dissatisfaction. Much of the dissatisfaction is from attempts to micromanage the community, and this has made community care “uncomfortable”. Laboratories, diagnostic imaging facilities, and other resources were essential for the community health care industry to thrive. As these “dried up”, community care has slowly wilted and may soon die. The response of our administrators in Calgary seems to be to create some new pots, the eighth and eighth downtown center, and the south of Anderson Road Health Center. The cost per patient seen in these facilities is twice that of private clinics that once existed throughout Calgary, and offer the same services.
In fairness, there probably are a number of care givers that can live in “containers” and be micromanaged. But for many of us, the freedom of the “back yard” is preferred, unless of course it has been covered with asphalt.

Wednesday, April 05, 2006

Medicare, Canada's God, Religion, and Identity.

I hate going to continuing medical education seminars! I’m not sure what the purpose of these events is. For the most part the speakers tell us things we already know, and show us in very specific terms that we are not doing the things we should be doing but almost never address the reasons we are not doing them. I suppose that may be a separate scientific session, although I can’t ever remember a seminar that asks the question: “Why are we as practitioners NOT doing those things we know we should be doing”? Filling us with knowledge and then pointing out what a miserable job we are doing (without determinating the reasons for poor compliance) isn’t the stuff that generates enthusiasm about attending the next seminar.
On previous blogs I have pointed out the vast reservoir of people in Canada that are at risk for cardiovascular complication and (for whatever reason), are not being treated. This has been referred to on previous blogs as a lack of fidelity in our health care system (getting the right treatment to the right patient at the right time). On April 6/06, at the University of Calgary, I attended a medical conference on osteoporosis, a chronic condition of decreased bone density combined with increased bone fragility, common in elderly people. It is estimated that this disease costs Canada’s health care system approximately 2-3 million dollars a day, without consideration of the pain and suffering endured by those patients who sustain fractures. I would think that the supporters and designers of our health care system in the 1960s had this disease in mind when they said the health care system should protect the poor, the chronically ill, and the frail elderly since many osteoporotic patients qualify for all three criteria.
There are many aspects to addressing this disease. It is two to three times more common in women than it is in men. With the recent trend away from hormone replacement therapy in post menopausal women, we can expect a surge in osteoporosis and its complications over the next 10 to 20 years. Most people are aware of fracturing as a complication of osteoporosis but few are aware that the mortality within the first six months of a fracture can be as high as 20% or higher, depending on the bone fractured and the age of the patient. With the cost, pain and suffering, and mortality rates in mind, one would think this would be an ideal area for our health care system to shine----not so.
Many preventative therapies are suggested. Adequate calcium and vitamin D intake, weight bearing exercises, avoidance of smoking and glucocorticoids, and using hormone replacement where appropriate, are all useful measures of prevention. Risk stratification can be useful (e.g. low body weight, family history, smoking history, excessive alcohol intake), but by far our greatest neglect in our health care system is the patients over 50 years of age that present with a fracture from relatively minor trauma (defined as a fall from a standing position or less). In this age group, 70% of patients presenting with a wrist fracture will have osteoporosis and need specific drug therapy; for hip and vertebral fractures the figure is closer to 90%. In Canada, the best figures that we have is 1/3 of the patients that should be treated with specific therapy are actually treated appropriately, and after one year the results are even more abysmal.
Unlike cardiovascular risk, where the identification of those that require screening can be a problem, identifying group at risk for repeat fracturing is simple; they present to the physician with their first fracture. What could be easier?
If a patient over 50 years of age presents with a fracture, part of the work up on this patient should be a bone density test to determine if this patient had a fragility fracture. If their bone density reveals osteopenia or osteoporosis they should be treated with specific medications----it’s that simple. When I retired 2 years ago, some provinces didn’t have the capability to do a bone density test. If we treated all patients over 50 years of age that presented with a low impact fracture, 10% to 30% of patients who wouldn’t need medication (depending on the fracture), would be on an expensive medication with the inherent risk of possible side effects.
The various lecturers had excellent statistics to show the cost effectiveness of doing the bone density measurements on patients presenting with low impact fractures. Since this group of patients have a two to three fold risk of having another fracture within one year and since appropriate pharmaceutical treatment can reduce the risk of repeat fracture by 40% - 60%, it would seem that this is a group of patients that a) meets the criteria that our system was meant to look after, b) is easily identified and c) can be cost effectively treated.
So why are we not treating them. The answer is simply that our system has poor fidelity (treating the right patient, at the right time, with the right treatment). We are preoccupied and paranoid with equality issues instead of focusing on the issues that pertain to the poor, the chronically ill, and the frail elderly, as the system originally was intended. The system has been high-jacked by the Friends of Medicare and other special interest groups (e.g. unions), and there seems to be a serious lack of leadership on the part of physicians to assist governments on refocusing on the poor, the chronically ill, and the frail elderly. How can we call ourselves a compassionate society when we support a monopoly that demands inclusiveness of people who have the capability of looking after themselves (at great cost to the system), at the expenses of those, through age, misfortune, or chronic illness, are unable to look after themselves. We have made “Medicare” our god and our religion. We have become totally dependant on it (it is a monopoly), pray frequently while we languish on risk lists, and don’t understand when our prayers aren’t answered. The fanatics, supported by special interest groups and the main stream news media, choke off any constructive discussion as zealously as any religious fanatic. Unfortunately, the carnage, although present, is not as evident. It exists all around us, in our friends, neighbors and relatives. It is the carnage of neglect, of apathy, and indifference. It is the carnage brought about by self interest, paranoia, and fanatic idealism. But we, as a society, keep it invisible and pretend it doesn’t exist within the system; and we physicians can live with it, just don’t go to any continuing medical education seminars.

Tuesday, April 04, 2006


The big question among many sociologists today is: “Why has Canada’s birth rate dropped to 1.5 children on average, per female? In other words, without immigration, Canadians would become extinct. This has been a trend now for many years and we are not alone. As I recall, France is at 1.1, and other European countries fare only slightly better. The U.S. barely holds its own at 2.1 children on average per woman.
As I pondered this question I recalled a discussion I had with a school teacher many years ago who had thirty plus years of teaching experience. We were bemoaning the fact that the “modern generation” seemed self absorbed. She reassured me that the pendulum would swing back; that as self absorbed parents, their children would be self sufficient and independent. They would have to be, in an environment that didn’t have the time of day for them. Wrong. This, and the preceding generation, have simply decided not to have children. Who needs the hassle?
And who can blame them? The following has been my experience in my medical practice and my conclusions, such as they are.
Like minded people “hang” together. There were some wonderful mothers in my practice who had three to five children. Interestingly, they all seemed to know each other and curiously seemed to have similar attitudes towards parenting. Even more curiously, this group didn’t seem to need the “valiums” and the sleeping pills. They socialized frequently and often did “relief baby sitting” for their friends. It wasn’t uncommon for a mother to come in with five or six kids in tow, hers and a neighbor’s. And the children seemed to be able to amuse themselves in the waiting room until the delegated patient was finished. And, yes, they were usually “stay at home moms”. There seemed to be a general philosophy among the children that the older ones assumed responsibility for the younger ones while mom was busy with “the patient”.
A classic example was a couple who had a three year old daughter and then was blessed with triplets. One would think that the daughter would be envious of the attention that was bestowed on the triplets. Surprisingly, even at that age, the three year old was enthusiastically involved with the triplet’s doctor’s visits, announcing in the waiting room whose turn it was next and supervising each examination.
On the other hand there was the group of mothers that had one or two children. This seemed generally to be a more stressed group of moms that attempted to do everything for their children, and felt their function on earth was to, at all cost, keep their children entertained, or, the alternate group who allowed them to grow up as weeds. And yes, there seemed to be a predominance of working moms in this group, but certainly a fair number of stay at homes as well. Generally speaking, these children seemed unhappy, didn’t relate well to others, and were more difficult to deal with. Don’t misunderstand, some of these children were “model” children (whatever that is), and the parents had obviously “dedicated” their lives to raising them to be upstanding citizens, but for the most part, anyone observing these one and two child families would swear celibacy. The parents were chronically tired, and the children chronically agitated. These groups have, by far, become the more common and more visible group.
An example of this group was a couple that believed “no” was a bad word and should never be used on children. Her visits were feared by all doctors in the medical clinic since the four and six year old virtually tore the place apart. One day as she was visiting the doctor and her children were rifling through drawers and emptying them on the floor of the examining room, she turned to her children and said: “Children, perhaps the doctor would rather you not do that”. The doctor replied: “It’s quite alright ma’am, I’m sure they will stop shortly after they get to the poisons”. Gladly, we never saw these people in the clinic again.
The point I’m making is that as a society our priorities have changed. When there were large families it was because families were valued and the people within the family units felt valued. Each family raised their children as best they could, and other people observed the results and patterned their behavior accordingly. In small subgroups within our society where families are still valued, we can still see evidence of success with larger families. Generally, in today’s society, the family is not valued to the same degree. It has been replaced with an attitude of “I want what I want when I want it”; two cars, a large home, continuous entertainment, and self gratification are a must. Live for today is our motto. Immediate gratification is our ideal and a “throw away consumerism” is the gold standard. This doesn’t really fit in with having and raising children----a life sentence. I sometimes wonder why we as a people are so blasé about the thousands of abortions performed in Canada every year; more evidence of our throw away society? You would be surprised to know how many abortions are performed annually in Canada on women who are married or in a stable relationship.
But I digress.
If we couple the above changes with the determination of other people to tell us how to raise our children, the simplest solution is to not have them. Any young person who comes in contact with their struggling and haggard married friends who are trying to meet their personal goals in “keeping up with the Joneses”, and still provide everything for their equally spoiled and self centered “only” child, will make the logical decision simply not to have children. We have senators and judges advocating against spanking because it is violent, sociologists and psychologists recommending to not use the word “NO”, lobby groups that push the idea that children are better off being raised in a day care than by loving parents, and government leaders that wish to spend billions of dollars on day care but have continually rejected the idea of splitting family income for tax purposes, so one parent could then afford to stay home with the children. More recently, we as a Canadian society have acknowledged through parliament, that non biologic coupling is just as valid and important to us as a nation, as biologic coupling. In this setting, our young women of today would need some pretty strong motivation to have children, or be pretty stupid. I know they may be a lot of things, but stupid isn’t one of them!