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?

Friday, July 28, 2006

Surviving As a Caregiver.

The purpose of today’s entry is to make one thing clear: When I refer to our Health Care System as lacking compassion and humanitarianism, I am criticizing the system, not the people working in the system. In the late 80’s and early 90’s when governments decided to do “something” about the ever increasing costs in our health care system, the mantra at the time was to take a more “business-like approach to health care. It is now apparent, some 15 years later that they have succeeded. Unfortunately, by its nature, looking after sick people is a caring and compassionate activity and attracts people who, by their nature, are caring and compassionate people. Businesses are by their nature self directed and self sustaining, and thus the huge disconnect between our Health Care System and the people working in it.
Dr. Gil Curry, the Calgary Director of Emergency Services states that there is a high level of stress leave, transfers, sick time, etc. reflecting the stressful conditions in the emergency departments in Calgary hospitals. It may be of interest to Dr. Curry that other areas of medicine reflect similar indicators of stress. Home care has problems recruiting nurses and a high turnover rate, family medicine is disappearing (I have known several family doctors who have quit and returned to University to train in some other field), and obviously the Region (from newspaper reports), lacks skilled O.R. nurses. My understanding is that family doctors do not have a long life expectancy and I do know that there is a high rate of divorce, alcoholism, drug addiction, and suicide in the medical profession.
I recall listening to a business leader back in the early nineties. His advice was that loyalty in business in the coming years would be a liability to workers and every worker should look out for his/her self. His position was that companies no longer look at loyalty as a positive trait. He suggested that to be successful as a business in today’s world, companies would be looking at the cheapest labor, have “crash” training programs, and have a high turnover rate. Long term employees translate into higher wages and expensive benefits. The Calgary Region fits in perfectly and attempts to hire part time employees instead of full time employees whenever possible. I am told by middle management executives that having a responsible attitude toward those working under you is not seen as a positive in the business world. The trend is to get all you can out of everybody and to expect high turnovers. Is this what we Canadians are looking for in our health care system? Obviously, this approach is “cost effective” as evidenced by the success of many of the large “chain” companies like Wal-mart, but do we really want a Wal-mart health care system?
For many people, working in our Canadian Health Care System becomes a matter of survival. As a caring person, how does one cope in a system that is uncaring? We can become “believers” in the “system”, and therefore what happens is justified to support the system, we can disagree with what we see and experience but tough it out and eventually suffer the ill effects of chronic stress (to say nothing of the effects this may have on our patients through poor performance), or we can transfer, change jobs, take early retirement, etc (basically move to an area that fits with out temperament and relieves the stress).
So my hat is off to all those who continue to survive and work in our health care “system”. Knowing what “should happen” and seeing what “does happen” on a daily basis is extremely difficult. My advice is to speak out more; caring and compassion should never be something that we should be ashamed of or hide.

Thursday, July 27, 2006

Blood Needed To Demonstrate Indifference

Three cheers for Dr. Chris Eagle, one of the Calgary Health Region’s Executive Vice Presidents. With reference to the Lundy miscarriage case he apparently made the statement to the press “We lost the human touch on this” and “This was a failure in the sense of being able to provide humanitarian assistance”. Right on!
Iris Evans, our provincial Health minister, apparently stated: “I’m hoping we don’t see this happen again. It’s something we can’t promise even if we had the right number of beds”. This statement unfortunately is likely also true.
In today’s Letters to the Editor in the Calgary Herald a writer states if Ms. Lundy wanted privacy she should have stayed at home, since first trimester miscarriages are common and no big deal.
All of the above illustrate clearly what my concerns are regarding our health care system in Canada. We have indeed dropped the ball, lost the human touch, and failed to provide humanitarian assistance, as Dr. Chris Eagle states; but not just in this case where a woman sits in an emergency department waiting room and bleeds onto the chair and the floor around her. This has happened in our health care system overall as the years have gone by. In this case, the episode was acute, visual, personal, in a public place, and because blood and reproduction was involved, the news media saw fit to put the incident on the front page. But I would ask Dr. Chris Eagle and the public this: “How much compassion and “human touch”, how much “humanitarian assistance” are we giving our elderly who wait in pain for their joint replacements, our cardiac patients awaiting investigation and intervention, or our cancer patients waiting for investigation, a treatment plan and treatment itself?” which is an ongoing, continuous state of affairs in our health care system.
Our Health Minister, Iris Evans, states correctly that this could happen even with adequate hospital beds. Since this is an attitudinal problem, she is probably correct, but having said that, we should be even more concerned. As Dr. Chris Eagle points out, technical problems have technical solution; what does one do about a pervasive attitude of indifference? This attitude stems from cost effectiveness being the “god” in our system, and it has replaced compassion, caring, and humanitarian assistance. These things cannot be measured, and to the “bean counters” and beaurocrats, they have no value. To the patient and old time family docs like me, it is often the most important part of medicine. Patients waiting for joint replacement may only have a few years left to live. They may spend half of their remaining life waiting in pain for their orthopedic or other procedure. In the mean time I, as their physician, give them anti-inflammatory drugs (for pain relief) that increases their risk of a heart attack, stroke, high blood pressure, kidney failure, and gastrointestinal bleeding, or I may give them opiates (codeine, morphine, etc) which increases their risk of falling, mental confusion, delirium, constipation, etc. Where is the compassion, the human touch, and the humanitarian assistance in that scenario?
Lastly, the letter to the editor states that women having miscarriages in the first trimester should stay at home. The case in question concerned a woman who miscarried at three month. Although miscarriages in the first trimester are common, fatal bleeding can occur; the farther along the pregnancy, the greater the risk. To me, the letter indicates that the public is at present making a choice; what is the risk, and what is the emotional price I will have to pay to get appropriate treatment? The lady who suggested in her letter to the editor that Rose Lundy stay at home with her “three month pregnancy miscarriage” is either not aware of the risk or is willing to accept the risk for her personal and emotional comfort and privacy. What a choice. I thought our Universal Health Care was to do away with those difficult “uninformed risky” decisions! Oh, that’s right----if they are based on money!
But our elderly people are making those kinds of difficult, potentially life-threatening decisions every day. Do I take the prescriptions for the pain in the hip that needs replacement and take the risks as described by my doctor, or do I live in pain for the next year or two? Do I go to the hospital emergency as my doctor recommended for stabilization of my heart failure and sit there for hours, or do I insist that my doctor initiate treatment as an out-patient and see if I improve. Many, many times, I have been begged by my patients to NOT send them to the emergency department. “Isn’t there SOMETHING you can do without sending me to the emergency” was a common statement made by many of my ill seniors.
So it would seem it has come to this; if you want caring, compassion, understanding, and a humanitarian approach, stay at home and accept the risk of dying. If you want practical, cost effective medicine that minimizes your risk of dying, go to the hospital, but expect to be approached in a calculated cost effective way. Will my risk concerns then be addressed? Sorry, only if they are cost effective and within the budget of the provincial government and your Health Region, but you will have the “perception” all is well. Ignorance truly is bliss.

Healthcare Emperor Has No Clothes

I am continually amazed by the apparent lack of perception on the part of the MSNM (mainstream news media) and its resistance to reporting the facts.. The headlines in Friday’s Calgary Herald read “Medic crunch raises alarms”. The article goes on to discuss some concerns on the part of aldermen and women of the city of Calgary pertaining to the fact that, on at least six occasions this year, no ambulances were available in the city of Calgary for emergencies. In Edmonton, this situation arose 18 times this year in the month of June alone! But “crunches” in health care should no longer be front page news; healthcare usurping all other public funding, should be.
The article appropriately points out that, should there be an emergency in the city, and no ambulance available, someone’s life may be in danger. What is not pointed out is that if the ambulance simply dropped off people at the hospital emergency departments and didn’t wait around, many more lives would be in danger. There are some basic reasons why the EMS people must wait around:
1) There may not be a bed in the emergency department in which to put the patient
2) There may not be a physician or other qualified person available to assume the care of the patient
3) EMS is run and paid for out of the City of Calgary budget, so the Regional Health
Authority is basically manning part of the emergency department using city finances.
4) Every patient must always have an authorized, capable caregiver assigned to them. The EMS person cannot leave a patient that is ill without another authorized person assuming responsibility.
Spokespersons for the region state they are at present looking at training and hiring persons to take on this responsibility in the future. Don’t hold your breath. They may put in a skeletal, token number of this type of staff, but the most cost effective way to run this area from their perspective is to always use the city EMS. The number of people accessing the emergency departments from time to time varies tremendously. To staff each emergency department in the city sufficiently, and not use EMS, would mean that very often the hospitals would, during relatively slow times, have these trained people standing around doing nothing. My guess would be that the region will put in a person or persons (we can’t have the perception that lives are being put at risk) sufficient only to minimize the “red alerts” that occur, but continue to use EMS to the fullest. The fact is that our medical system is putting lives at risk everyday with long waiting lists for a myriad of services. I suppose we should all take solace in the fact that the risks are “calculated” risks (categories of emergent, very urgent, urgent, and elective), and that this is being done in a cost effective way. The other fact that we should all be aware of is; Similar to the Calgary’s Health Region usurping the resources of the city of Calgary, our Canadian Health care system is usurping resources from many other worthy and competing interests-----education, infrastructure, the environment, etc. There is only so much taxpayer’s money to go around. When health care siphons up (like a huge vacuum cleaner) an increasing share of public money annually, someone suffers or is put at risk. When will the main stream media (MSM) get on side on this issue? For years headlines have been “raising alarms”; but all we hear are the same clichés and reassurances, while over the years our health care system has slipped precipitously in the eyes of the World Health Organization. When will the News Media see that “Our Health Care Emperor is not wearing Clothes”?

Monday, July 17, 2006

Herceptin, Practicing Due Diligence

“For the dollars in your program budget, you want to make the biggest difference possible”. This statement, according to the Sunday, July 18/06 Calgary Herald, was made by Dr. Tony Fields, one of the Vice Presidents of the Alberta Cancer board. This clearly states that there is a finite amount of money budgeted for cancer drugs in Alberta, and decisions are made as to what cancer therapies are covered; in other words, not all effective cancer therapies are covered. The above statement was made by Dr. Fields as Alberta deliberates as to whether the breast cancer treatment drug will be covered. I wonder how many lay people understand the significants of his statement. Please don’t misunderstand me, I think the statement is true and the people who are asked to decide “what drugs will make the greatest difference” within the confines of a finite budget have a horrendous job. Basically, a conscious decision has to be made between which cancer treatments will be included and which will be excluded. What we all need to be asking, and what we all should be told, is on what basis are these decisions being made?
Let us take a practical example. If you are one of a hundred people annually in Alberta who are diagnosed with a certain uncommon form of cancer, and the treatment of this cancer is $100,000.oo per person, it would cost the Alberta Cancer Board 10 million dollars a year to take on this coverage (let us say that research shows the drug extends life expectancy by four years). At present, the board is budgeted to cover a more common form of cancer (1000 diagnosed in Alberta per year) at a cost of $10,000.oo per patient, and this has been shown to extend the life of this group of patients two years on average. The cost to the Cancer Board of this last group also is $10,000,000.oo and results in 2000 patient years. The first treatment group only yields 400 patient years for the same ten million dollars. On a fixed budget, the Cancer Board would likely be justified in rejecting the first treatment, even though it adds four years to the patient’s life if it required a discontinuation of coverage for the second group. The Question NOW becomes; Will you be told that there is a drug available that could add four years to your life but is not covered in Alberta for financial reasons, or will you be told the drug hasn’t been tested sufficiently at this time? After all, not paying for a drug that can add four years to the lives of 100 Albertans is a poke in the eye of the Alberta government and the Alberta Cancer Board from a political perspective.
Herceptin IS expensive and impacts a LARGE number of people annually (breast cancer patients). So if the Alberta Cancer Board pays for it, what other drugs will NOT be included in their coverage as they practice “due diligence”?
The problems in cancer treatment reflect the problems in our health care system as a whole. Costs continue to rise as treatments improve, decisions (which we are not a party to) are being made to control costs, and patients are not fully informed as to the basis of those decisions. Since we are not fully informed, we are not fully aware of our options. Not being fully aware of our options can lead to erroneous decisions on our part. Some people may feel that their life is worth twenty five thousand dollars a year or more, but are not given a choice.

Thursday, July 13, 2006

A Nose For Cancer

Today I attended the funeral of a previous patient and friend. This isn’t the first such occasion since my retirement and I’m sure it won’t be the last. One never gets “used to” losing friends and former patients, so the event is a downer in its own right; but the thing that gets me are the tragic stories leading up to the event.
In this particular case, I had last seen this friend at Christmas/04. He had obviously lost weight and looked somewhat lackluster to me and I mentioned this to him. He chided me since I had always pushed him to keep his weight down (he was a diabetic), and related to me that he was merely being more attentive to his diet since his blood sugars had been somewhat more difficult to control. I had suggested he see his new physician and have a thorough work up none the less. Apparently he saw his physician as I had suggested---several times up to a month ago---- at which time he was taken to the emergency department and properly investigated-----inoperable and terminal cancer was his diagnosis.
I have been told by a number of specialists in the past that I have a peculiar “nose” for cancer. On many occasions I have insisted on certain investigations by them which yielded that diagnosis. But what really is a “nose” for anything? In medicine the primary prerequisite is know the patient. On one occasion many years ago before fancy CTs and such, a patient had the usual work up for abdominal pain, which revealed nothing. On strenuous urging from me the surgeon did exploratory abdominal surgery-----and found cancer. The surgeon wondered how I had known. It really wasn’t difficult. This particular patient hardly ever saw me, and when he did, he usually downplayed his symptoms. On this occasion he had seen me three times in three weeks with complaints of unwellness and persistent abdominal discomfort. At the age of 60 with no other findings to explain his symptomatology, the diagnosis was not surprising.
My friend that we buried today, that seemed to have lost that spark, that glow of health that he usually exuded, apparently continued to slowly lose weight. At first his physician bought into the “diet” thing’ and after many months and visits, it was suggested that he may have been depressed. His appetite slowly decreased, and finally when he reached 130 pounds of body weight, his family took him to the emergency department.
This man was 74 years of age, six feet one inch tall, and had a stable weight of 190 pounds for most of the years I knew him. Why suddenly would his attitude to diet and weight control change? Why suddenly would his blood sugars start to become unstable? And then there was that distinct lack of “spark”, that loss of the glow of good health. It is true that people who become depressed can have that “dull” appearance, but I often wonder how many people, who become depressed in later life, have an underlying cancer. Has anyone done a study on this? I recall seeing a patient from Saskatchewan who was diagnosed with depression. He had been losing weight and strength. His final diagnosis was wide-spread metastatic cancer. Sometimes I wonder if the patient, at some level of their subconscious, knows they have cancer, are in some kind of denial, and express themselves by being depressed. To most everyone, cancer is certainly a depressing disease.
The family of my friend today related to me that little investigation was done until he was taken to the emergency department. In the emergency department, the appropriate testing made the appropriate diagnosis, and an attempt was made at doing the appropriate surgery. Unfortunately, the cancer involved some major structures and nothing could be done. Had the diagnosis been made one year ago, would the results have been different? Very likely!
Is it really that some physicians have a “nose” for cancer (like apparently dogs can now be trained to have), or is it simply knowing the patient as a living, breathing, feeling human being, and being tuned in to him/her as a person. Perhaps not having the “nose” is from fatigue, apathy, too much to do in too little time, or simply an ongoing erosion of basic principles of medicine such as listening to and giving the patient every benefit of the doubt. Whatever it is, I don’t like it! I’m tired of going to friends and previous patient’s funerals.

Monday, July 10, 2006

Ghetto-izing Health Care

A retired teacher told me a while back that the education system had reached a point of deterioration such that she felt she could no longer function as an educator. She was able to relate the various steps of deterioration along the way, and the people and special interest groups that were involved in the transition. Unfortunately I am not able to do so, but the basic steps were as follows:
1) Many years ago someone thought (and possibly rightly) that our children with special learning needs were not receiving the attention they deserved.
2) Special classes (facilities) and bussing (access) was set up for these children at considerable cost to the education system.
3) Then it was decided that the system would lend itself to feelings of inferiority, and segregating in this group of students was not conducive to there mental well being.
4) People in high places grabbed on to this premise and decided to integrate children with special learning needs into the main stream classes (besides much money could be saved by doing this).
5) To placate teachers and concerned parents, it was agreed that teacher’s aides would be put in place to assist teachers since now these students took up a disproportional amount of the teacher’s time.
6) Because of cost factors, class sizes have slowly grown and teacher’s aides have been become a scarce resource.
7) Parents with children who did not have special needs, became concerned that their child was not getting enough of the teacher’s time. Some decided to home school and those that could afford it often moved their children to private schools.
8) This increased the relative number of special needs children in each teacher’s class.
9) My understanding is that somewhere along the way the department of education felt that a percentage of their cost to educate a child could be applied to the cost of private schooling (probably with pressure from parents who believed the cost of education should “follow the child”).
10) More parents could then turn to private schooling for their children and as a consequence, the ratio of special needs children in each teacher’s class in the public system again increased.
To me, the above scenario is an example of how well meaning people, made well meaning decisions, and “ghetto-ized” our public education system (segregation through social, economic, or legal pressure).
To my consternation and horror, on the Rutherford radio talk show a few days ago, Alana Delong (one of the Alberta Tory leadership hopefuls) suggested that perhaps this was the way to go with our health care system. The government could look at their cost of a treatment in the public system, go to the people who are on a waiting list, offer them eighty percent of the projected cost of doing the procedure, and the patient could go to a private provider (if they wished to jump the queue) and pay the difference, thus shortening the waiting list.
What a bone head idea! Firstly, you can bet the government will “low-ball” their projected cost. Secondly, it blatantly underscores the check-book or credit card as the way to get faster treatment; and it takes away incentive for government to provide more resources to shorten wait lists in the public system. They can simply foist patients off on the private sector, and the patient’s bank account, at a fraction of the government tab. Through benign neglect of the public health care system, governments could indirectly coerce patients to opt to pay for their own health care or stay in the equivalent of a “death camp”. The end result would eventually be a public Medicare Ghetto where the poor, the frail elderly, and the chronically ill would be segregated into a public health care system that has a strong disincentive to provide Universal Care, and has as its most successful cost effective policy, coercing people to use the private system. God help us!