Public Opinion, Is It Public Enemy # One?

You will just have to excuse me. Today I will do the unforgivable. We all have a breaking point and I have reached mine. After all, blogs can be used as therapy, right? And I need therapy. After watching the ABC presentation “The Path to 9/11”, I simply have to say something about how I feel. Yes, I know I’m a man and men aren’t supposed to be capable of expressing their feelings according to Oprah, but perhaps I’m the exception to the rule, because here I go!
I truly believe the biggest threat to law and order and good government is PUBLIC OPINION.
Just think about it. In democratic countries all levels of government get voted “in” through some type of majority and get voted “out” by the same process. The driver behind this process obviously is “public opinion”. This is our Democratic Achilles heel. The only thing that democratically elected officials and governments have to fear is public opinion. Previous prime ministers routinely used poles to decide policy (obviously Prime Minister Harper doesn’t). Jane Taber and Greg Oliver repeatedly raised the issue of decreased support in Quebec regarding the Afghan issue with questions like “But aren’t you concerned about decreased approval in Quebec. How do you expect to get a majority government? The question wasn’t “is it good policy”, or “is it good for Canada”; it was more a “you better watch out” kind of thing. Governments seem to function based on “How do we get public opinion on our side? When Jack Davis was sent to Calgary by the government in Alberta, he was to change the “perception” that we had a health care problem in Calgary, and that perception was causing public opinion to turn against the Klein government. Any type of reform involving private care in our monopolistic health care system has always been put in abeyance by special interest group’s lobbying and influencing public opinion. This one issue has to a large degree determined the governments elected over the past fifteen years.
While watching the events leading up to 9/11, it would appear that many times the Clinton administration failed to take action because they “feared how it would play out to the public and the press”. Which brings me to the second conclusion; and that is the MSNM feel they own the gun (public opinion) and can pull the trigger on public opinion any time they wish. Note the struggle between the Ottawa News Media and Steven Harper. The struggle basically is on control of public opinion. The MSNM recognizes their strength is through their ability to help form public opinion, and by doing so control and determine which party will be in power. Stephen Harper is also very aware of the power of public opinion, but wishes to determine the direction of the government and its policies on the merits of the issues, based on the information provided. Limiting the ability of the MSNM to manipulate public opinion by having orderly question periods and giving everyone a fair chance to ask question (not just the most aggressive) is simply following the first rule of confrontation: “Know your enemy”.
On a global scale, the various terrorist groups of the Middle East learned a long time ago there was only one thing that democratically elected leaders feared, and that was public opinion. And they quickly learned how to use it. Unencumbered by the usual games and frailties of political correctness, truth, negotiating in good faith, fairness, peace on earth, etc. they simply played to our sympathies and portrayed themselves as the victims, continually using our media and freedom of speech, to sway public opinion in their favor. In their country, the media has been strictly controlled, and only the messages they wished the public to hear were ever heard. They have used public opinion throughout their nations and, indeed the world as a whole, for recruitment of suicide bombers, raising money, preventing aggression from other nations, and even managed to paralyze the United Nations and the European Union (and the Canadian NDP party).
So it would seem the MSNM has it right, those who control public opinion control the most powerful weapon in a free society. With the MSNM wanting so desperately to have control of this weapon, it seems to me, crucial to know, “Are our guys with us or against us”?
Even more importantly, we must recognize that our opinion has tremendous impact on the government that we will have, and the policies that the government will bring in. We must always seek the truth, knowing that many would try to influence us to their way of thinking and their values. When the world was larger, and the MSNM did not have the slogan “It’s not the story, it’s how you tell it”, we could reasonably rely on the news media to relate factual material. Today we must always be aware of the potential spin and the desire to help formulate public opinion, and the power of that public opinion in democracies. I have often been asked on telephone surveys about matters that I know nothing about. Most often I still present an opinion on the matter. Wrong!!! I should simply say that I am not informed enough to have an opinion on the matter. Just consider how uninformed most of us are when we get out of our area of daily function, and still governments tend to develop policy based on the accumulation of that ignorance. I certainly do not endorse media or special interest censorship. Free speech is vital to a free society. But I do endorse the utterance of an informed opinion. Remember, your opinion is part of the larger opinion called “public opinion”, and that has the power to cause great nations to wring their collective hands and do nothing in the face of a threat like 9/11, not to intervene in the genocide in Dafur, or for that matter, decide the fate of the failed nation, Afghanistan. So the next time you are asked for your opinion in a pole or survey, remember, your opinion is going to help shape the policies of the free world, or not; so if you don’t know what you are talking about (which of course doesn’t include any of us), keep your opinion to your self, your family and your best friends. But do not, I repeat, DO NOT, make it part of a “PUBLIC OPINION”.
There, I feel better already.

Appeasement, Short Term Gain for Long Term Pain

Every once in a while I venture out of my comfort zone of experience (medicine) and wonder into adjacent, but at the same time, distant, areas. Over the last few years, and I suppose, because today is Sept/11th and the fifth anniversary of one of mankind’s greatest acts of inhumanity, the word “appeasement” has come up as a strategy for dealing with terrorism, terrorist groups, and rogue nations. So in my usual obsessive-compulsive way, I began ruminating about the situation, and in my overly simplistic way, I applied my experiences in family medicine to the world stage, and the premise that “appeasement” is the solution and approach, that should be taken to the aggressors in this world (My dictionary defines “appease” as “to make calm or quiet, esp. conciliate (potential aggressor) by making concessions). My first reaction to the discussion point was ‘When does living in harmony with conflicting views, deteriorate to negotiating peace, then to appeasement, then to enabling, then to aiding and abetting, and then to abdicating all the things that we believe in? Is the slippery slope the negotiating? Or even before that---simply talking about our different opinions (many friendships have been destroyed by talking politics and/or religion)? After mulling over these imponderables, I got a headache, and decided I would leave those hefty intellectual exercises to men, er----persons, wiser than I.
Now, back to the topic, my medical practice experience with “appeasement”; could I think of instances in medicine and human behavior, where this was a useful and beneficial approach to aggression?
Of course! The well known and respected “baby soother”. Whenever the baby is unhappy and invades our peace and solitude with piercing screams and cries, stop what you are doing immediately, and plunk that wonderful little nipple facsimile into her/his mouth. What’s the worse that can happen? Sucking a soother at school at age ten when unhappy? Big deal, kids have to learn to be tolerant. Come to think of it, there may be a time when the soother doesn’t work and the infant wants the real thing plus warmth, reassurance, company, visiting, singing, entertainment. So what if it is in the middle of the night and the child is two years old, surely a little appeasement, say a cookie, in response to the discontent this once, er—twice, er---five times won’t do harm? Anyway if this starts to fail, you can always appease them by taking them into your bed with you; that usually is very soothing and comforting to children. Besides, it acts as a fairly good method of birth control. Mind you, when they reach puberty (well, actually even maybe before) you had best find some alternative appeasement method. Child services are suspicious of aging children sleeping with their parents. O.K., maybe the soother wasn’t the best example.
How about a cookie to appease children who scream, cry, yell, turn blue, etc when you are trying to visit. That can’t be so bad. Oatmeal cookies are healthy, and you will only do it when you have company, ----- and I guess when you’re shopping, er, and in a restaurant, and, well, I guess in public. Well, maybe at home too, but only if he does it for more than five, or maybe two minutes when we are at home. And of course, if I want to sleep; but that is actually a negotiated compromise, right? But I’ll be tougher on him when he gets older and he understands more and I can reason with him. I won’t try to appease him then-----unless he threatens to burn down the house, of course. Well, what else could I do? O.K., I guess I could have bought him the car he wanted even though he was only fourteen. So, O.K., maybe the appeasement cookie wasn’t that good an idea.
I know. Appeasement works in situations of marital dysfunction. Say the husband likes to have his meals exactly on time and gets yelling and aggressive if they are ten minutes late, just make sure his meals are always on time, and show him his shiny shoes, he always settles down when you show him his shoes that you shined. And when he starts yelling and shouting, just say “yes sir”. That usually appeases him. Except, of course last time, when he hit you because he thought you were being a smart ass (were you?) Maybe the doctor was right when you saw him about that black eye. The aggression and abuse does seem to be getting worse in spite of your best efforts at appeasement. I guess that wasn’t a very good example.
Of course, here is a good one. My daughter had a very aggressive and hyperactive six month old dog that she needed help with. Being a kind soul, she took the dog to an obedience school that believed in the carrot and not the stick. During the first class the dog was uncontrollable in the new exciting environment and barked continuously. At first the instructor reassured my daughter that under the circumstances (new environment, other dogs, etc.), her dogs behavior was normal. After thirty minutes of ongoing chaos (I think the chewing on people and furniture may have had some impact as well), the instructor gave her dog a “doggy” biscuit. The dog lay down quietly and ate the biscuit. Peace at last! Everyone cheered. A great example of appeasement. Unfortunately, bad behavior returned two minuets later and the remainder of the session was spent feeding the dog various treats. The next session was worse, and, after being satiated with treats in the first twenty minutes, the dog proceeded to destroy the environment around him. The instructor deemed the poor dog as incorrigible, and my daughter and her dog were expelled from the class. Perhaps the instructor was right, the dog is incorrigible (although he behaves perfectly with me in all circumstances), but as I write this blog entry I am starting to have some doubts as to the benefits of the “appeasement” process and philosophy. In fact, I have a suspicion that it may be a process where short term gain leads to long term pain. Perhaps I just need more time to think about it.

Canadian Medicare, Another Failed Utopia

The thought occurred to me the other day that the reason we hang onto Canada’s “Universal” Medicare system is that it represents the “ideal”; the utopia of health care in a society. As normal biological creatures, we have a strong drive to move to comfort (who wouldn’t want total comfort guaranteed?), and therefore any perceived impediment to that movement is resisted and considered to be counterproductive and an enemy to the public’s best interest. It supposedly follows that to achieve the “ideal”, no regard for conditions, prerequisites, or stipulations are required, and everybody should have all their needs and comforts attended to equally in every respect. The other side of this equation is that, unfortunately, there are thirty million Canadians who all have unique needs and wants, and not having a want fulfilled generates frustration and discontent, and therefore stress; a very unpleasant phenomenon.
The truth is that as a society, and as a people, we have many wants, needs, and often different priorities, and most, if not all of them, are dependant in some way on resources (in the broad sense), and therefore, money. Resources and money on the other hand are directly related to productivity in the broad sense, and in particular, effort; again, one of those things that requires us to be somewhat uncomfortable (note that we know many things we do are harmful to us, but effort is needed to change them and their eventual result).
The point is that our original Medicare System was seen (and is still seen by some) as a health care utopia, and as is the case with all utopias, they eventually self destruct because of the complexity of human nature. Communism and other social structures that were purported to be “ideal”, have demonstrated that as time goes on, more and more regulation and micromanagement is needed to address the dissatisfactions of the people within the “utopia” and maintain its “utopian” perception. The more control imposed, the more people will find control measures objectionable (note the objections to airport security that is designed to safeguard the people using the facility and planes). Dr. Rachlis has stated that it is better to build a fence at the edge of a cliff than a hospital at the bottom of it; but the question again arises as to when your “fence building” creates a corral, a containment that is objectionable in a free society. Addressing the problems of one group to try to achieve perfection creates problems for another group. Soon the supposed “utopian” society pleases no one other than those that cling to its ideological intention. Further, any attempt at change is made impossible by both the forced micromanagement and control, and the fear of loss of the “ideal”. Is it any wonder that the Canadian Health Care System continues on a downward spiral? Handicapped by the utopian ideology, that a system of “one size fits all” is ideal, and can be devised, stagnation and decay sets in.
Perhaps the premise to start with should be that we are all unique and have unique needs and wants and “comfort zones”. The ideal system in Canada then, with its thirty million people, would be a system with at least thirty million health care options (thirty million “tiers”, if you like); each one perfectly designed for each person, with each person determining their own “tier”.. True, this “ideal” can never be met to perfection, but wouldn’t we at least be on the right road? And wouldn’t it be better if each one of us were given the opportunity to at least look at options, and decide where our priorities lie, and how we wished to participate in those options? We have gone a long way down the road in our attempts to give life support to our present “utopian” health care system; but from what I can see, there is no question that both the Canada Health Act and our Canadian Health Care System have passed their “Best-Before-Date”.

Nursing Homes, Part of the "Shell Game"

The discussion of health care needs, and the “shell” game as to where the needs are being “stashed”, would not be complete without talking about our “long term” bed allocation.
In order to have any understanding of this situation, we must understand that there is a language in the health care administration field that is unique and changes frequently. The term “long term care beds” is equivalent to the old term “nursing home beds”. I note in the Calgary Herald, Sept6/06, that the term “hospital beds”, now includes beds used for “rehabilitation” and “recovery”, which now are likely to be located, and have replaced many “nursing home beds” in long term care facilities. As an example, the “once upon a time” Glenmore Auxiliary Hospital” which was a facility for long term patient care (not truly a hospital, and the beds were not included in the calculations for “acute” care), with an expanded capability for complex long term care, is now primarily used for “rehabilitation” and “recovery” care, and included in the “hospital bed” to population ratios given in the Herald’s article. I note with interest also, that the figure given for acute care beds in 1990/91 is 2.67 beds per 1000 population which likely reflects the “beds in use” at that time. The truth is that our capacity was much higher since at any time, the hospitals had wards with beds that were not in use, but could be opened up should the need arise; quite different from the existing situation. Don’t you just love statistics and the administrator’s ability to pick and choose their presentations?
To get back to long term care beds, the province had a moratorium on the building of long term “bed building” back in the 1980’s and early nineties. Although mostly privately built and privately owned, the government picks up most of the cost of long term care and therefore decides when beds are needed and when they are not. Like other government activities, they used “guidelines”, and the guideline they had decided on was, I believe, 50 long term care beds (including “lodges”) per 1000 population over the age of 65 years (At one time we were at 57 beds/1000 seniors in Calgary, thus the moratorium). Don’t ask me how they came up with the “ideal”. In any event, with the moratorium, and the push to decrease cost in our hospitals, it soon became obvious to the administrators in the region that money could be saved by transferring people from hospitals to nursing homes (and as mentioned in previous blogs, to the community as a whole). With this, a new administrative animal was born: “The Placement Assessment and Coordinator”. With this, neither the patient, or the family doctor, had any say in where the patient was “placed” for care. The “placement coordinator” decided the patients “needs” and the most appropriate location of their care. As a result, patients were often placed miles from where their loved ones lived and their family doctor of many years practiced. This resulted in many family doctors discontinuing the care of many of their long term patients, and indeed, many of them giving up nursing home care and hospital care entirely. Of equal concern, as a consequence of this downloading policy, units (consisting of many beds) in the “long term care category facility” became specialized areas of care “used” by the hospitals to “dump” patients. I use the words “used” and “dumped” because although these beds were designated beds for: recovery, transition, rehabilitation, and palliative care, little was done to upgrade the facility and augment the personnel to accommodate that increased patient care NEED. Further, little was done to monitor or measure the changing mandate of care and whether it was being addressed adequately or appropriately. Little wonder advocates for the seniors in these institutions are concerned, and news headlines are beginning to appear pertaining to the care of our elders in long term care facilities.
Where we are today in the old ratio of long term beds per 1000 seniors population, the Lord only knows. The moratorium ended some years ago, and since then some beautiful nursing homes have been built, Sadly, most are grossly understaffed for the care expected, and most are sadly lacking in access to investigative management. Where at one time, lodges provided assistance (at reasonable cost) to elderly patients who required health care assistance, (but did not require nursing home care), expensive assisted living accommodation has come on the scene and is a fast growing industry, the cost of which is fully borne by the patient. Whether the beaurocrats admit it or not, health care has, and is changing rapidly, and the chronically ill, the poor, and the frail elderly are bearing the major burden from a cost and care perspective (the very group our system is to protect). We seem to be shocked almost daily by situations arising in our hospitals and emergency departments, an area of visibility. We certainly can keep score of the casualties in the conflict in Afghanistan. Too bad no one can see what is happening in our own communities and the various “invisible” community facilities, and the casualties that are occurring there!

The "Shell" Game, Dumping Health-care Needs Into The Community

Recently Dave Rutherford had the CEO of the Capital health Region (Edmonton) explaining what a good job the various Health Regions in Alberta were doing, and I suppose indirectly, justifying the salaries administrative types make. Calgary Health Region’s senior vice president of people and learning (don’t ask me what that means), Margaret Munsch, said in Thursday’s Herald that “The compensation reflects their accomplishments as individuals”. So let us take a look at the accomplishments of administrative types at all levels of health care in this province (especially Calgary).
1) Wait times in our emergency departments have grown drastically. Ten years ago we were upset at waiting times of one and one-half hours. Today wait times exceed four hours.
2) There have been longer waiting times for various surgical procedures such as joint replacements.
3) There has been an increase in waiting times for specialty consultations.
4) There has been an increase in waiting times for diagnostic investigative procedures. There has been an increasing delay in many cancer treatments.
5) There has been a decrease in family doctors (and specialists) doing obstetrics.
6) There is a drastic decrease in family doctors with hospital admitting privileges.
7) There has been an increasing proportion of the government’s budget going to health care during this same time (out of proportion to inflation and population growth).
8) There is a drastic shortage of family community doctors (now in Calgary alone estimated between 200 to 300 doctors).
9) And there has been a very impressive increase in the salaries of administrators!
But our administrative friend from the Capital Health Region states that innovative ways of providing medicine has occurred.
1) Hospital stays per procedure or per disease treated are decreasing.
2) More people can be treated as out patients.
3) The cost of hospital care as related to the total health care cost in the Regions is going down (didn’t mention that the cost of community care is skyrocketing, which is of course the other side of the cost equation).
And the above three statements are absolutely true; but what isn’t being said is:
1) By downloading patient care from hospitals to the community, we have conscripted the loved ones of the ill as care givers, and their beds as treatment beds. This is cost effective because instead of $1000.oo a day for a hospital bed, the family takes on the care of the patient with minimal support from the system, eg. palliative care and home care nurses drop by periodically and the region will kick in up to $3000.oo a month to beef up care for palliative care patients (a savings of 27,000 dollars per month per patient).
2) Home treatment programs aren’t assessed as to patient and family impact (someone taking their holiday time to care for a sick family member, someone quitting their job to care for a dying family member, the stress and exhaustion of family members staying up day and night to care for their dying loved one, etc.). I’m not saying that care in the community is not necessarily appropriate. I’m saying that it is not adequately compensated, and the system is taking advantage of the loved ones and the community care-givers!
3) Early discharge is not being critically assessed as to patient and family impact.
The problem is that by downloading health care NEEDS into the community, no tools are being used to measure the impact of the innovative “cost effective” practices that we herald as advances. In hospitals we are able to look at waiting times in the emergency departments, hospitals putting patients in hallways, surgical wait times, etc. In other words tracking and visibility is easy and unavoidable. Ten years ago I strongly recommended using “known “tools” for tracking health care needs in the community on an annual basis, to see the impact of the changes being brought about in the Calgary Region (this was being done by some of the consumer groups in the U.S. to monitor the activities of HMOs in the U.S) To my knowledge this still is not being done by the Calgary Region (What independent consumer groups in Canada and Alberta are tracking health care provision here?). In effect what we have here is a “shell” game ----- “Bet you can’t find where the sick people are?”
The process is simple and is comprised of a questionnaire sent out to a random, statistically significant number of people in the Region. The questions would be as follows: IN THE LAST YEAR
1) Have you been ill?
2) Did you see a doctor?
3) How long did you have to wait?
4) Were you investigated?
5) How long did you have to wait? a) in the Laboratory b) for a diagnosis, c) X-ray, Ct scan, MRI, specialist.
6) How would you rate your experience?
7) How much time from work did you miss?
8) How much time was needed from other members in your family (or friends) to attend you or assist you?
9) Are you still having problems?
10) Have you had pain?
11) How would you rate your pain (from 1 to 10 with one being little pain and 10 being the worst pain you can imagine).
12) How long did you have pain for?
13) Do you have a family doctor?
14) How far do you have to book ahead for a complete check-up?

You get the idea? There are standardized “tools” (much better than my effort above) that have been used for years and reflect the community “burden” of health care needs similar to emergency wait times, surgical wait times, etc. To my knowledge this is still not being aggressively pursued. Think about it; health care needs are being put into the community where no-one can see the impact------except of course, those poor unfortunates that happen to become ill (and their families), and are deemed to “not need a hospital bed”.
Don’t get me wrong, many cases are more appropriately treated in the community. But in the face of an increasing shortage of family physicians, an increasing population, an increasing percentage of seniors, and increasing health care costs (which, it seems, providers and provinces are all trying to contain), wouldn’t it be nice to know how we are coping in the community with the most vulnerable in out society. In this case, what you don’t know may in fact “hurt” you! Available acute care beds in Calgary have dropped from 3.3/per 10000 people to 1.8/per1000 people. The health care needs of the people of Calgary have actually been increasing per 1000 population with increasing age, obesity, diabetes, etc. The people that once were treated in hospitals are now treated in their community. Do the highly paid administrators know how well the chronically ill, poor, and frail elderly are doing in the community? Does anyone besides the sick patients and their families know how well they are coping? After all, the Health Regions and
their administrators, are responsible for all health care provision in their regions, directly or indirectly, not just the care and budgets and care in the hospitals. And from what we can see from a community health care and access perspective, most of us wouldn’t consider it worthy of the increases given.