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?

Saturday, June 24, 2006

The Ten Commandments.

What a beautiful morning! At last sunshine and the ability to get out into the yard and enjoy the wonders of nature; this in direct contrast to the last few rainy days when I had been house bound and had to resort to reading blogs to fill in the time. Not that it hasn’t been interesting and possibly even intellectually stimulating, but depressing.
In particular I found the discussions on SDA pertaining to a terrorist taking a small girl by the hand (so as to get closer to his target) and then blowing him, the small girl, and the target to pieces, distressing. As repulsive as this behavior was to me, some of the bloggers (steve d, George, and neutralsam) seemed to have no trouble at all justifying this action. In spite of ET and others patiently trying to explain why this is different than many other forms of violence, these bloggers held firmly to their beliefs, and in the discussions, although occasionally having a point, used it in such an obtuse and irrelevant manner, it reminded me of religious discussions back in my University days. People with a strong belief system can’t seem to concede the slightest point. It would seem that by conceding one thing, their entire belief system begins to unravel causing incredible angst.
Strangely (or perhaps not so strangely), my thoughts turned to Ann Coulters latest controversial book “Godless”, in which she describes “liberalism” as the religion of America’s political left. Then my mind moved on further and I thought “If this is true of the USA what does that say about Canada? Has Medicare become one of the Ten Commandments in this new religion; others being public education, universal day care, social safety net, military peacekeeping only, subsidizing and rewarding failure, etc (Ten Commandments= Canadian Values)? Or has Medicare become a god unto itself with physicians and hospitals being the priests, Provincial Health Ministers the Cardinals, the federal Health Minister the Pope, and the Canada Health Act the Bible?
Man, this stuff is too heavy! Like I said, I’m glad the sun is shining today and I can work outside with Mother Nature, but one does have to wonder!

Wednesday, June 21, 2006

Yay! I'm a Canadian

Yay! I am now a true Canadian by virtue of being on a medical wait list. After two and one half years of severe back and upper leg problems and by virtue of the sudden onset of more pain associated with significant numbness of my left upper leg, I was given the privilege of an MRI that showed a significant protrusion of my L2L3 disc to the left, resulting in a referral to a back surgeon. I was also given the advice that should I loose bladder or bowel control, I would need immediate surgery. In fairness to the physicians and staff at the emergency department that I visited, they were all extremely professional and courteous and I thank them sincerely; but the fact is that I had been having back and upper leg pains for two and one have years with intermittent transient weakness in both legs off and on for over eighteen months. A specialist that I attended some six months ago suggested that I may have early spinal stenosis and said that “if I wished” a CT of my spine could be done.
What happened to the physicians that stated “you should have the following done so that I can make a definitive diagnosis”? My response was likely typical of many Canadians at this time: “Well, the doctor doesn’t seem too concerned so why take up space in an area of scarce supply”, or, “we have to work together to control health care costs”.
Still, there are people like Dr. Dennis Furlong (written up in the May9/06 issue of the Medical Post) who is strongly against a parallel private system (but feels the present system is unsustainable) who feel the solution is to add another tax to the Canadian tax system. He states (from the Medical Post): There should be a system of prorated patient participation in the cost of their care. It’s called accountability, and it’s been categorically avoided by all studies and reports to date”.
What planet is this fellow living on? The acuity of visits to the emergency departments of our hospitals is steadily rising. Trivial complaints are almost non-existent in Calgary emergency departments these days. A recent study shows that only twenty five percent of our hypertensive patients (at major risk for strokes and heart attacks) are being treated to target. How is adding their treatment to their tax bill going to give the seventy five percent of hypertensives (at present not being treated or inadequately treated), incentive to address the issue? Besides, I thought this universal system was brought in so that people would not have to worry about the cost of seeing a physician or getting appropriate treatment. How can Dr. Furlong’s plan not be seen as taxation on the ill in our society? Is it really so difficult to understand that a healthcare system within a society should care for the poor, the chronically ill, and the frail elderly, and that a parallel private insurance system could look after the “unexpected” health-care events. Further, I would suggest that a government “universal” system has an obligation to seek out and treat the chronically ill, and I would categorize the people with hypertension as “chronically ill” (being asymptomatic does not mean you are not ill). As a recent study shows, thousands of strokes could be prevented annually in Canada if the people with hypertension were treated to target. So let’s not blame the ill patient for the cost of our health care system. I fear that many already are not receiving the care they should be getting by an exulted “save the health-care system” attitude on the part of physicians, advocacy groups, and patients themselves (to say nothing of aggressive cost saving measures by governments). Let’s get back to a public health care system that has a mandate to look after the sick, and not worry about whether the sick can get private insurance. If we do it right, everyone will get better healthcare.

Tuesday, June 20, 2006

The Ostrich Syndrome

There is an interesting article in the June/06 issue of the Canadian Journal of Gastroenterology----interesting and disturbing. The specific article is titled “Canadian Consensus on Medically Acceptable Wait Times in Digestive Health Care”. First, I’ll give kudos to the editor and the submitters of this article for having the courage to honestly put forward information (as best as is possible) on the issue of wait times and state “comparisons of these bench marks and actual wait times will identify limitations in access to digestive health in Canada. Secondly, they should be reprimanded for not having the courage to categorically state, with the present day knowledge available, that they recommend the wait times put forward in their article. Instead they “cop out” and throw in the caveat “These wait times should be considered targets for future health care improvements and are not considered to be clinical practice guidelines”.
Another obvious negative on the part of the article is the fact that there is so little information available on the impact of waiting on certain medical conditions in gastroenterology (in spite of the authors looking for information in “Medscape”
and other scientific publications), and still the authors, as medical people, did not raise this as a concern. They certainly mentioned this lack of research in the article make no specific comments or recommendations regarding this fact.. If anything, they have the gall in their two month waiting category to list many conditions that have a prevalence of 5% to 10% incidence of colon cancer. I feel that most people would not accept a waiting time of two months if they were told they had a ten percent chance of colon cancer. The article states that to “confirm” colon cancer, (the diagnosis has been suggested strongly by some other modality, eg barium enema) a two week wait should be the maximum since waiting in that situation could be detrimental to the patient’s well being. Obviously, if you are one of the ten percent with colon cancer on the first waiting list, the two month wait has been detrimental to your health.
I found it interesting that, in doing their research, this group found considerable information on the “cost effectiveness” of doing procedures in a given time frame but no information on that same condition as to the harmful effects to the patient of delays in doing the procedure at a given time. Good examples of this are patients with significant lower bowel bleeding when they are an in-patient. Doing a colonoscopy within twenty four hours gets the patient out of hospital quicker and therefore is cost effective. Since only 5% to 10% of these patients have colon cancer, a statement could not be made as to the benefits to the patient of doing the colonoscopy on an urgent basis.
The critics of private health care alternatives always point out that the private system is “profit driven”. It becomes clear from this article that the public system is “cost effect” driven, and in the big picture amounts to the same thing. Money “saved” in the health care system can be then spent to garner votes from other special interest groups, competing social issues, infrastructure, education, etc. If a parallel private system existed, the patient could shop for options. In our monopolistic present day health care system, there is only one game in town.
What is clear in this article also is that we, as a society and a profession, really don’t want to look at, or have too many studies, on the impact of our waiting lists on our citizens. Like our attitudes in many other areas, the “ostrich head in the sand” routine has become a Canadian Value.

Tuesday, June 06, 2006

Family Physicians Headed for Extinction

And of this you can be sure, in our public health care system, the traditional family doctor who comprehensively looks after the medical needs of a family, is going the way of the infamous “dodo” bird----- extinction. In June’s Vital Signs, the Calgary and Area Physician’s Association news letter, President Dr.Glenn Comm bemoans the fact that people in Calgary are having increased problems finding a family doctor. He also points out that many of the training positions available at present in Canada for family doctors (residency positions) are not being filled for lack of applicants. He notes that increasingly, those that choose the training of a family doctor, end up working in some capacity other than that of an office based, comprehensive family doctor. He muses about some possible causes for this, some trivial, like a lack of family physicians in teaching positions (likely because they don’t pay them adequately), and one major, money (notice how in spite of the “experts” and the socialists saying more money won’t help, the lack of it continues to be a problem. Besides, if additional money is not the answer, why is it that the socialists feel that in a more open system the wealthy would have an advantage? Odd!).
Here are his reasons:
1) Regional Health Authorities hire family physicians away from the community to fill service gaps in the Regions health services; hospitalists, specialist physician extenders, or staff at urgent care centers such as Calgary’s Eighth and Eighth Center. The pay is per hour and it is without expenses and the hassle of running a family practice. Usually access to resources is better and you don’t need to worry about finding a locum if you want time off---just tell the clinic manager when you will be away.
2) Some family physicians work as locum tenens (replacements for physicians with established practices when they take time off) at a rate of approximately 70% of their billings. Since office overhead runs at approximately 50% of a physician’s billing, it is clear that the family doctor with an established practice pays dearly to take some time off. When I did locum work last year, my net take home was equal to my gross billings from my previous family practice. So why not do locums; more money and you control your work schedule.
3) Dr. Comm mentions the rising costs in Calgary (rent, salaries, etc) with no way of passing these costs on to those receiving the services. This would apply to specialists as well, but the disparity between specialist’s incomes and family doctor’s incomes is considerable and continues to grow, so why not specialize. Dermatologists and Ophthalmologists are among the professions top billers and are able to have more control over their lives.
Now I would like to add some “money” related causes of my own. One of the main reasons that I retired was the chronic shortage of resources and the inability to have a patient investigated in a timely fashion. In this same June issue of Vital Signs, a long practicing family physician in the Calgary region wrote a letter to the editor stating that he and family physicians in the region had received a letter from the pediatric cardiologists in the region. The letter apparently advised family doctors in the region to be more discriminative in their referrals of children with heart murmurs. In their view (the pediatric cardiologists), many of these children had benign murmurs and the cardiologists work load was increasing with corresponding increases in wait times. At present, echocardiograms in the Calgary Region, on people under the age of eighteen, cannot be ordered by anyone but designated pediatric cardiologists. The family physician in question thought that opening this up to family physicians and pediatricians might decrease the need for cardiology consultation. This idea was rejected because of the likely increase in cost (more echocardiograms would likely be done) and there is a shortage of technicians, so waiting times would get longer. The pediatric cardiologists felt it would not decrease the need for a cardiac consultation and they may be right. The fact is patients want to know specifically and exactly what is the cause of the heart murmur, what is the outlook for the future, should there be any change in the activity level of the child with the heart murmur, should the child have prophylactic antibiotics before dental appointments, and a whole host of other questions from the internet; not the least of which, “who do I blame if you are wrong”. The family doctor, without the pediatric cardiologist’s opinion and the tools to investigate, bears this responsibility alone at present. The dentists frequently telephoned me with the antibiotic question. My answer should be factually backed, and I think the pediatric cardiologists and/or investigative modalities should be there for us and the patient. If they want to lean on the general pediatricians to take more responsibility, so be it, but get off the backs of the family doctors. Keeping up on all areas of medicine is an incredible challenge and we can’t be expected to be all things to all people. Besides, when I started practice, my annual premium for malpractice insurance was $25; now for equivalent coverage, a family doctor would be looking at an annual premium in excess of $6.000.oo.
Every specialty department takes their pressure and tries to download work and responsibility on family physicians. A few years ago, the regional department of radiology sent out a letter advising family physicians not to talk to the radiologist for CT bookings that were urgent-----just send in the form with the relevant information and mark it urgent (the radiologists didn’t have time to discuss the cases personally with the family practitioner). The radiology department would give priority to the requests based on the information given. As deputy Chief of family Practice in the region at that time, I advised the Region and the Department of Radiology at the time that deaths would result from this policy. As if fulfilling a prophesy, one month later a patient died while waiting for a CT scan of the head even though the request for the CT was marked urgent. The Region settled the lawsuit out of court and the policy since has been changed.
The courts of the land do not hold “paucity of resources” a justifiable excuse in a court of law----and rightly so. But it puts the family doctor and the patient hanging out to dry. The family doctor is in the ideal position to deal with most things in medicine today, but without the resources, our hands are tied. And money is needed to expand our resources and our capacity.
At present, the big push in our health care system is to find ways of downloading work on less qualified people, often without the support necessary to do the job. The advent of nurse practitioners, physician extenders, pharmaceutical assistants, team approaches, and more recently, prescribing pharmacists, are a few of the ways the system is attempting to get an equivalent service for less money (albeit by a less qualified person). At some point, there will be a realization that the comprehensive care given by a family doctor, has been, and still is the most cost effective health service in the system. But as the saying goes: “I never missed the water until the well went dry”!