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?

Thursday, November 30, 2006

Naomi and the Left Versus Ted Morton

Today I wasn’t going to post, and then I read Naomi Lakritz’s column. I know, haven’t I got anything better to do? I guess my only excuse is that she wrote about healthcare and the leadership candidate’s position on it, and, well, I kind of lost it. I guess she is just one more person criticizing a private care alternative, but not offering ONE suggestion on the present day issues on health care in Alberta, or Canada for that matter. Here are some of her mindless positions taken:
1) Iris Evans dropped the third way because the people didn’t want it. What percentage of Albertans had any idea of how it would work. We should probably pay attention to an informed majority; but the usual clamor from the left drowned out any effort at rational dialog. Personally, I think the people of Louisiana should have listened to the suggestions of evacuation long before they did. It would have saved hundreds of lives. I would preferentially listen to a fireman on how to get out of a burning building than the throng of people below. Sometimes leaders should lead.
2) An AON consultation did not guarantee privatization would save money. Here is a news flash: only an idiot would guarantee savings in health care. I would think any increases in cost would then have to be borne by the consulting company. Besides, there are two significant problems in our health care system at present, increasing costs and long waiting lists. A parallel private system would shorten waiting lists by better utilization of surgeons. Even I don’t think there would necessarily be a cost savings, BUT: a private system with private insurance will provide money from those people wanting to be covered by a private system, and thus take less money out of the governments taxation “pot”.
3) She quotes Ed. Stelmach: “Allowing doctors to practice in both a private and public system will not put more doctors into Alberta communities”. Well Ed. and Naomi, it probably would. WE have lost thousands of doctors and nurses to the U.S. and elsewhere over the last fifteen years. Just maybe, if we offered them more options in their practice, with a recruitment program that showed our appreciation of their contribution to society, we could get many to return to Canada.
4) Apparently she approves of Jim Dinning’s comment: “Albertans have said they don’t want it, so I’m not going there”. Mr. Dinning knows the present system is unsustainable. He also knows that five federal elections and lord knows how many provincial elections, have been won largely with a “status quo” stand on health care, in spite of the fact Canadians want it fixed. I notice, Naomi, that you have not made ONE positive suggestion in your column.
5) She apparently likes Jim’s “allowing doctors to practice in both systems would draw doctors to the city ------“. Now where is the evidence for that? Surgeons, especially orthopedic surgeons, already practice primarily in the large urban centers, and rightly so. This is a blatant scare tactic ploy on Dinning’s part to try to garner some rural votes. Pathetic!
6) She criticizes mandating certain obligations on the part of physicians to spend time to the public system. Congratulations, Naomi, you got one thing right. Forcing people to work where they do not wish to work really is autocratic. Fortunately, only five percent of physician in Canada would prefer to work only in the private system. It does, however, open the door to a viable and active recruiting program that can attract hundreds, and maybe thousands of doctors to Alberta/Canada.
7) She states that there is not a market for private care or more doctors would be in private care already. She states that it’s because the market for people who can afford to pay upward of $30,000.oo out of pocket for a new hip is extremely limited. Duh! Isn’t that precisely why we commoners should have the right to purchase INSURANCE? Even without the insurance, people are dipping into their savings and going to physicians in the U.S., Vancouver, and Montreal. Naomi, the dyke has a huge leak, and will soon burst without some kind of relief.
8) She quotes Dr John Kortbeck, CHR’s regional director of trauma “Countries with a private system have found that the public system still does the bulk of surgery” and he apparently adds “our operating rooms are running at between 90 and 100 percent utilization rates, with some open 24/7 to accommodate a balance of emergency, urgent (cancer surgery), and scheduled (hip replacements, etc). I certainly agree with Dr. Kortbeck’s first statement. My guess would be that only twenty percent of surgeries would occur in an insurance based private system; and this would vary with the type of surgery and the length of waiting lists in the public system. For example, if hip replacement waiting lists are two years or longer, the private system for hip replacements may grow to a 30% market share. If waiting times for hip replacement in the public system shrinks to thee months, the private systems share of hip replacements may shrink to 5%. His second statement underscores the fact that according to him, the system is doing as well as expected. A good question for him, Naomi, would have been: “Why don’t we run more of the surgery theaters 24/7 and shorten some of those waiting lists for cancer and hip surgery?”. Do you suppose his answer may have been “lack of money and staff?”.
So that is the sum of it; an opinion column on health care that had one purpose only, to slam Ted Morton as a leadership candidate. Her opinion is most noteworthy by the lack of knowledge of the subject matter demonstrated by the writer and the obvious bias. But then, it was only an opinion, and like arse holes, everybody’s has one (but only proctologists are happy about that fact).
Tomorrow, I will attempt to explain in detail how a parallel system would work, what it would do and wouldn’t do, and how the two systems could complement each other. Yes, I know, the human brain will reject anything that causes conflict or stress (cognitive dissonance), so I will be wasting my time with Naomi and the like; however, for those simply looking for information, it may well be worth the time.

Wednesday, November 29, 2006

Motivation, The Primary Determinant of Health

Although our Alberta Conservative leadership candidates don’t seem to want to talk much about healthcare, and Ed Stelmach didn’t even have it on his top four priorities the other day on “talk radio”, healthcare continues to take front page space on our Alberta newspapers. Today, Nov.29/06 edition of the Calgary Herald informs us of the Calgary Health Region’s intent to “construct” (not really true since someone else will “construct” and the Health Region will rent) a 75,000 square foot Health Centre in the unhealthiest part of Calgary. This clinic will replace two existing clinics that a) “aren’t adequate to meet service needs, b) “are unable to provide the unique services needed in the area” c) really doesn’t meet (our) needs. The Health Region then intends to purchase the building back from the “contractor/financer” of the building. I hope that during these times of escalating construction costs, the region has their contract nailed down, no pun intended.
The major point of my entry today is to ask the question of the Calgary Health Region: “What are these needs that are not being met and what is the plan to meet them, and at what additional cost”? Staff increases are stated to be more than 10%, and the only reasons that I can find to justify this move pertains to “life styles” and as a result, I would surmise, a shorter life expectancy. These areas have “the highest rate of smoking, smoking while pregnant, individuals that don’t meet daily nutritional needs, lowest birth rates, and highest rates of unemployment”.
Dr. Brent Friesen, the regions officer of health, said “One of the things that the Calgary Health region is doing, at the present time, is that we are partnering with other groups because the solution to a number of these problems lies outside the health system as a whole”. After pointing out that this group of people are not meeting their nutritional needs, he goes on to say “If people are on a fixed income, then they have to find the money from other areas, and most often the area they get that money from is the diet”. Well, I say “Amen” to both of those statements; but why do they not take that money from their smoking budget, bingo and entertainment budget, etc? Walking is free and gas is expensive. Now, there is a trade we could all make!
The only reference in the article I could find as to the “unique” services to be offered are “diversity and translation services for immigrants, and wellness programs to reduce smoking and obesity. Twenty new employees are planned for the center; I certainly hope they are sociologists and psychologists because this may come as a surprise to Dr. Ed. Friesen, but I suspect that there will be a low enrollment rate in his programs. Contrary to the prevailing belief in many areas at present, I do not believe that poverty and poor education, per se, are the determinants of health. Rather, they are simply the symptoms of an underlying pathology, poor motivation. I know, I know; variation in motivation is probably a normal genetic variant, similar to many other inherited characteristics, but are we as a society ignoring the important environmental factors that can assist development or potentially retard development of motivation? Some people are truly gifted athletes but never show up on the radar screen of performance; others with a fraction of the genetic ability become Olympic athletes. Some people may misconstrue the word “motivation” and combine it with the words “ambition” and “greed”. I prefer to think of it as a need for self improvement. This may mean different things to different people (the state of one’s spirituality and mind, is more important than the state of one’s body), so perhaps it is unfair to have “health measurements” as a measurement of motivation, or motivation as a determinant of health outcomes, but it is more valid than anything we are using at present.
As a farm kid I was very familiar with the expression “the cream always comes to the top”. There was something magical and intrinsic in cream, so that after a period of time, the cream would separate from the skim milk and rise to the top of the milk bottle. That does not mean that cream is necessarily better (although I think it was implied). Because it has certain characteristics, it simply differentiates itself from the milk. I truly feel that people that are motivated will differentiate themselves along the pathways that they feel are important; that they value. This certainly can be influenced by an environment of hope, the exclusion of mental illness, and a host of other environmental factors. But I have learned over the years that a host of other environmental factors can negate our motivation. Imagine my consternation when, many years ago, I moved to the city and found out that when you homogenize the milk, the cream doesn’t rise to the top anymore. Are we as a society trying too hard to homogenize the people in our society? Are we perhaps putting incentives and disincentives in the wrong place? By guaranteeing the status quo, are we feeding our fear of change and thereby taking away the hope of improvement? Or even worse, by rewarding inertia, and dwelling on the risks of moving forward and the sacrifices that would have to be made for independence and self improvement, are we neutering motivation? And what part do high taxation and inappropriate handouts have in this process? If we did a survey and asked people if they valued their health, likely 100% would say that they did. Yet, we find that only twenty percent of people will invest their time, energy, or money, in their health. Why the disparity? Do they really "value" their health, or do they feel that it is not their responsibility and are simply "entitled" to good health?
Today’s entry is not made as a condemnation of the poor, but rather as a commentary on our society as a whole. Why are our young people spending their money on cars, televisions, toys, etc, when these things depreciate by 30% a year when real estate in Alberta is going up at the rate of 30% a year? Obviously, they have different attitudes, priorities, values, etc. Is this wrong? Not necessarily, but along with it seems to be an increase in an attitude of entitlement. A recent “pink book” by a particular federal women’s group seems to epitomize this. If this is their version of “fulfillment” or “self improvement”, we are in trouble as a society.
So by all means, build and staff a medical clinic in North-East Calgary. But for heavens sake, make it a pilot project and hire sociologists to look at motivation. Throwing more money at these problems, I suspect, is simply part of the homogenization process that actually prevents the cream that is in all of us, from rising to the top.

Tuesday, November 28, 2006

Canada's Healthcare Tsunami

Outraged readers of my previous post suggesting outsourcing of Canada’s healthcare needs, as a solution to the rising cost of our Universal Healthcare System, should not read today’s post. After all, if the idea of outsourcing our wealthy people to the U.S.A., as is now occurring, and our poor to India (a future consideration), as a solution to health care costs, is a problem for you, then, today’s post may be totally offensive!
It has been said to solve the problems of today, we must often look to the past. Mark Steyn, in his book “America Alone”, goes to great lengths to show the impact of demographics and an aging population within a given society. It is hard to argue with his observations pertaining to demographics; however, I will confine my comments to the impact on health care. Further, I do not wish to get into the arguments put forth by economists (percentage of GDP, percentage of government budgets, etc). It is not my field, so we will leave that to the bean counters. From a medical perspective, and a common sense, here is how I see it (perhaps a more appropriate title would have been “The perfect Storm”):
1) The edge of the wave of baby boomers is now about 60 years old. The evidence is that these people will slowly and continually become increasing consumers of health care more than contributors to health care, i.e they will be hospitalized more, see the doctor more often, etc. and at the same time, they will be retiring from the medical and other work forces, creating both a shortage in health care providers and a decrease in the tax base supporting the healthcare system.
2) Canada has a reproduction rate of 1.6 children per woman. Therefore each generation continues to shrink compared to the generation before it. The relative size of the baby boomers to the tax-paying base of the population will therefore continue to rise.
3) Life expectancy continues to creep upward while reproduction rates continue to creep downward, with a corresponding increase in the disparity mentioned in #2.
4) Modern technology and pharmacology have dramatically increased our ability to intervene in the usual mortality, but not necessarily in the numbers of people requiring ongoing costly “maintenance” therapy and cost. This not only incurs the cost of the intervention and the maintenance therapy, but increases the effect of #2 and #3.
5) Within western societies, there has been a steady increasing empathy for the weak, unfortunate, elderly, disabled, mentally ill; well just about everybody in need. Whether this is good or bad is irrelevant; the net effect of this has been that, as a society, we have tended to bring about the two-fold effect of decreasing our tax base and increasing our “dependant” base with the corresponding increase in cost.
6) Underscoring all of the above has been our resistance to defining “what is a need as opposed to a want in our just society”.
So where will this all end? We have this tidal wave of elderly, demanding, and high needs people being maintained by a relatively decreasing supportive group in our society. Sounds like a societal “Katrina” to me.
I started this post by suggesting some of the answers may lie in the past. Environmentalists may also be showing the way. Perhaps the old saying “radical situations need radical solutions” is correct after all. With the global warming that has been reported, there have also been reports of increasing ice flows and ice bergs. Northern civilizations in the past (faced with the harsh reality of survival), took the most dependant and aged in their society, put them on an ice flow, and wished them “bon Voyage”. Most health care costs are accumulated in the last two years of our life, so that type of a policy could save over fifty percent of our societal health care costs! What’s that, you say. Some countries have introduced and legalized euthanasia with the same principle in mind? Well, then; it would appear that we have come full circle. Isn’t it amazing how things always work out?

Sunday, November 26, 2006

Steyn's America Alone

Since childhood I have always been an avid reader. One of my regrets throughout my medical career has been the time commitment to reading medical material and the time demanded by the job itself. One of the “perks” of retirement, for me, is the opportunity to continue my medical journal reading, and at the same time, expand my reading outside of the field of medicine. Recently I have started reading Mark Steyn’s “America Alone”. Whether you agree with him or not, I find the book quite intriguing.
In particular, I found his statement that Western civilizations have lost their “stomach” for war, very interesting. The statement conjured up visions of how violent mental patients were controlled in mental hospitals some seventy years ago, before the advent of our psychotropic drugs. These poor patients reacted to their aberrant visual, auditory, and in general, sensory hallucinations by being aggressive to the point of, not only harming others, but being a danger to themselves. Confinement and restraints would only limit their destruction, certainly not prevent it.
The solution was to administer a drug called epecac. This drug could cause continuous vomiting to the point of exhaustion and total submission. Could this be the origin of the expression “I can’t stomach that”? If that is the case, the Main Stream News Media certainly are the “Epecac” of our modern western civilizations. For most of us, ongoing scenes of death and destruction is a “stomach turner”; especially when we are made to feel we are responsible for the death and destruction.
Steyn talks about how important it is for a society to have the “will” to succeed and survive. I guess this struck a positive note with me because I feel the determinants of health are related to the motivation (read “will”) of the person to improve their own health.
So why would some societies have a strong “will” to survive and others not have the “stomach” for it? Besides the epecac theory, my aging agile mind (????) turned to our two barn cats. That’s right, our neutered, but not de-clawed, barn cats.
Since I live on an acreage, about every two months, a stray cat comes along and finds my heated barn/garage more comfortable than the underside of my garden shed. Plentiful food probably increases the attraction. The usual scenario is that the stray cat (usually a Tom) slowly sizes up the situation, moving in closer and closer to the food and comfort over a period of days, and eventually, through body language, hissing, spitting, scratching and biting, takes over the food and comfort of my barn and garage, relegating my cats to the -20 degree temperature and no food under the garden shed. Now, I wouldn’t mind if these stray cats helped themselves to some food, or even some warmth on a cold night, but really, why should my cats be out under the garden shed, cold and hungry? After all, they are the chosen ones!
My solution has been to capture these invaders and take them to the SPCA (I don’t have the heart to shoot them). I know, I know, they are likely euthanized in a less cost effective way; but how else am I to deal with it? You see, my cats primarily are concerned with the entertainment derived of catching and playing with the occasional mouse (food and housing is a given for them), and even more concerned as to where they are going to get their next petting and strokes. Survival for them doesn’t appear to be an issue until they are faced with the stark reality of the underside of the garden shed and it is too late. On the other hand, these visiting cats don’t seem to believe that possession is 9/10ths of the law, or any law, for that matter, except the law of survival. Without my intervention, my dependant cat’s survival would be in serious doubt. If we, as a society, don’t have the “will” to survive, who out there will rescue us or intervene on our behalf? Or for that matter, who and what is the human equivalent to the SPCA. And how, over the past two generations, did the western societies become neutered and dependant? And why does the MSNM keep feeding us epecac? So many questions and so few answers!

Friday, November 24, 2006

Who's Hot, and Who's Not, in Alberta Healthcare

It’s the eve before our big election in Alberta, so I guess I’ll do a run-down of our “premiers-in-waiting” from a “vision of healthcare” perspective. Keep in mind this is my humble opinion only, and should not in any way be considered a “professional” opinion, since I have only met four of the candidates briefly, and have relied mainly on what I could find of their opinions in print (consider this a disclaimer).
1) Mr. Gary McPherson
This is the candidate that I admire most. In spite of personal hardships, or maybe because of them, my impression is that he has learned in life that your success or failure depends on your own efforts. He also seems to know that asking questions gets you more information that preaching to others. He was the only candidate that asked my opinion on healthcare, although they all said that they, as premier, would be prepared to listen. I do believe, however, unless he put an incredible team together to help him, the job is beyond his capabilities.
2) Dr. Lyle Oberg
In the area of healthcare, Dr. Oberg has a huge advantage. I am aware that during his years of family practice in Brooks, he ran a large practice that covered the full scope of family medicine, including obstetrics. I know he has also been consistent in his attitude that private medicine needed to play a larger role in Canada. I do wonder, however, if he has the leadership skills to rally the support of conservatives in Alberta, since he doesn’t seem to have the support of his fellow cabinet ministers in spite of many years in cabinet. In fairness, his approach to healthcare may be frightening the others off; let’s hope that’s not the case. It bothers me that in the past few months, he has shown a tendency to “cut and run”. Not a characteristic we need to deal with Ottawa (well, maybe?).
3) Ed Stelmach
Unfortunately for Ed, I had an opportunity to speak with him personally on health care issues. He seemed to know little about the Barer/Stoddard report that began the decrease in physician training in Canada and seemed to feel the Alberta College Registrar, Dr. LeRiche was to blame. Although Dr. LeRiche had socialistic approaches to most things, I doubt if his influence was Canada wide. Perhaps I should have introduced myself as a physician before he started lecturing me on healthcare. I could find very little substance on healthcare in his web site, and generally felt I was getting a “pep talk”. His “pep talk” approach seems to have won him support; but not mine.
4) Mr. Doerkson
Victor seems to have bought into the present “politically correct” determinants of health, poor education and poverty, instead of looking at the determinants of poverty, poor education, and poor health. He strikes me as a kind man, who, if given a specific task, would do a reasonably good job of it; however, he strikes me more as a follower than a leader.
5) Mr. Mark Norris
Mark was the only other one to answer my enquiries; unfortunately it appeared to be a computer generated response. My overall impression of Mr. Norris is that he may feel that technology is the answer to most things, although I must admit, he seems quite personable. He seems to be big on the “micromanagement” of healthcare, and I couldn’t find any real new vision in the healthcare field. Mark, we need more people in the healthcare trenches. Bean-counters got us into the mess we are in today.
6) Mr. Dave Hancock
I’m sure Dave can talk for hours on health care and the many solutions to every one of the problems facing the Canadian Healthcare System. After all, he is and has been a politician most of his life. My impression is that Dave talks a good game, and can philosophize at length, but isn’t much of a doer. Perhaps that is a good thing since I get the impression that Dave is more than a little left of centre. I’m sure, from what I have read from his web site on health care, he could easily increase Alberta’s healthcare budget from the present 10 billion dollars, to twenty billion dollars in the next four years. Unfortunately, in spite of these expenditures, I suspect healthcare outcomes in Alberta will not have changed.
7) Ted Morton
I would like to see Ted win, but I fear he won’t. He has said very little about health care other than he feels we need more choice in healthcare providers in a free democratic society. He is aware that you cannot provide infinite services from the finite taxpayers pockets, and by having private services, people can have a choice, albeit by financially taking responsibility for their health. He seems to have more faith in free market systems as one would expect of a conservative; and has had the ability in a short period of time, to mobilize significant grass roots support. The MSNM seem to be giving him a fair amount of press, and I wonder if they feel he would be a more vulnerable target in a provincial election than Jim Dinning, thereby giving the Liberals a better chance (My paranoia acting up). He seems to have no fear in speaking his mind, and I think it would be refreshing to have him as the next Alberta leader of the Conservative party.
8) Mr. Jim Dinning
I have had both the pleasure and the frustration of working with Jim in the healthcare arena. He is bright, personable, and although he can talk an excellent political game, unlike Mr. Hancock, Mr. Dinning is a doer. The question becomes, who will be the major recipient of his interventions. Being a very capable politician, I get the impression that when it comes to the difficult decisions, unlike Mr. Harper, Mr. Dinning will “blink”, generally throwing in with the ”powers that be”. At this point in time, Alberta does not need an appeaser on the national scene. Capitulating on the many national issues facing Canada, and Albertans in particular, is not in the best interests of the average Albertan. Perhaps I am being unfair to Mr. Jim Dinning, but he knows better than anyone that the existing healthcare system is unsustainable. His not speaking out on the side of a parallel private system with doctors practicing in both systems speaks volumes (or is it my paranoia once again raising its ugly head?).
I predict that Jim Dinning will win it on the second or third ballot, largely because the existing caucus will not have the courage to back Ted Morton and will push their respective followers to take the “safe route”. Hopefully, I will be wrong.

Candidates Favorite "Visions" for Healthcare

Before I give my “two cents worth” regarding the candidates for premier of Alberta, I would like to focus more on some areas of medicine that seemed popular with many of the candidates. These were often offered as solutions to the increasing cost of health care across Canada and in particular, Alberta.
1) The electronic health care record.
The experience of practitioners, who have gone to computerization, is that it has actually increased their costs. In Alberta there have been, and are, specific programs to offset these costs, but these programs will end, at which time ongoing costs will be borne by the practitioner. Savings, such as reducing unnecessary repeat testing, are savings to the system, not savings to the practitioner. Improving the tracking of chronic diseases has positive implications for better quality of care and preventative medicine on a personal and global scale, but will mean significant increases in cost in the short term (ten to twenty years), both to the taxpayer and the practitioner. Implementation of “privacy” safeguards will be a huge problem, and have significant cost and administrative implications.
2) This is especially true when putting this together with the other area of enthusiasm, the Primary Care Network (PCNs). Their vision is that, by definition, primary care is the first point of contact with our health care system. Strictly speaking then, the person who answers the phone on Calgary’s present “Help Line”, is a primary health care worker. They fore-see also, community health clinics, where people will be triaged, not necessarily to family physicians, but possibly to physiotherapist, chiropractors, dieticians, optometrists, nurse practitioners, etc. so many, many people will be primary and secondary health care providers, and part of the health care team. Sounds like a real “team effort” so far, right? The caveat on all of the above is, however:
3) Confidentiality. The “vision” is that information should only go to the health care worker if it is needed to perform their duties to the maximum of their “scope of practice”. Whoops!! Whose job is that? Sounds like it may fall in the lap of the family doctor, if there is one. And for heaven sake, how do you set that up on your computer? If you have a moderate sized practice you may have to hire a programmer to set it up, and even then, spend most of your time trying to decide what information to send along to which member of the health care team. Keep in mind, legally, at present, there is pressure to have written consent on the part of the patient before information can be sent along.
Here is the dilemma. I have a patient that is depressed and attempted suicide two months ago. She has been referred to a psychiatrist, and of course it is important that the psychiatrist knows of the suicide attempt. She has a problem with obesity and self image, so I refer her to a dietitian. Should the dietitian know about her attempted suicide? It certainly may reflect how important losing weight may be to this patient. She also is seeing a physiotherapist for low back pain of two months duration. Should the physiotherapist know about the suicide attempt? What if the back pain began with her crashing her car into a cement structure? What if it predated her “accident”?
The bottom line is that in a truly integrated computerized health care system, with the Primary Health Care Networks presently envisioned by the government, we may as well kiss confidentiality “good-bye”. Every health care person that comes in contact with the patient (and many who will not), will have access to the medical information on file. In order for that not to happen, there would have to be a “medical information watchdog” responsible for providing information to care-givers on a “as needed to know basis”. Whoever takes that job had best have lots of insurance against law suites. All in all, a complex, costly “vision”, and a make work project for lawers.

Thursday, November 23, 2006

Dave Hancock, a Lawyer's Perspective on Healthcare

The first thing we have to understand about Dave Hancock is that he has been in politics since 1974. The second thing we need to understand about Dave is that he is a lawyer. The first thing that crossed my mind when I read his “bio” was “Why doesn’t Dave, who has been in politics since his youth and all of his adult life, held many important portfolios in the Alberta conservative government, have more support from the Conservative caucus and Alberta Conservatives in general? The answer, I believe, can be found on his web site while reading about health care issues.
First you will have to take many hours out of your day (as I have) to read the reams of material. Secondly, when you are finished you will probably not know what he said, but will have a distinctly uncomfortable feeling if you are a conservative. Perhaps it is all the “buzz” words and phrases that he uses (that I have heard over the last fifteen years while I wasted my time on numerous committees). Words like collaborate, focus, comprehensive, innovate, guarantee, ensure, teams, commitment, maximize, effective, coordinating, and on and on and on------. Phrases like cost effective, medically necessary, assessed need, social and mental well being, root causes, province wide strategy, and more recently “Full Capacity Protocol” are driving me crazy! If only “coining a phrase” could solve a problem, Mr. Dave Hancock and our political medical planners over the past 15 years would have solved everything years ago.
I certainly don’t intend to comment on all of his material, but rather, try to determine where he stands on critical issues in health care (You of course, are invited to review all of his material, and point out the errors of my conclusions).
1) On private Health care-----Dave states that it is a difficult question (yes, we know that). He also states it plays a significant role now (We know that too). Should we have a public system?----he says we should; all Albertans must have timely access to quality care regardless of ability to pay. We are all in agreement with that, Dave, but you see, they don’t have that NOW! He states there has been too much discussion on Public verses Private already. Wow, I missed that part. When did it happen? Then he gets on to prevention. Healthy life styles, etc, etc, etc. The same old mantra. Mind you, in another section we will look at his “healthy life styles” solutions.
2) Doctors remuneration-----There is no easy answer to this is Dave’s response. He reports that technologies have benefited some physicians but not others and physicians should be rewarded for their time, expertise, and responsibility. Well you have been in Cabinet for the many years that these disparities have been occurring and family physicians providing comprehensive care have been disappearing. We, the public, and I, the family physician, wanted to know how you were going to address the problem. Stating how things “should” be doesn’t “Git-er-done”.
3) Health funding------Dave’s Response: “New and innovative thinking, spur innovation and competition, standardized performance measures, engage leaders, create a Health Care Policy Coordinating Council, and focus on being well (There you have it folks, that’s how you fund our public health care system. Need I say more?). When asked under this same topic about funding issues such as Fort McMurray, aging populations, etc, he states there needs to be flexibility. Duh! But how do you propose to actually install the flexibility feature? Oh, yes, you again mention healthier life styles.
This review would not be fair without looking at Dave’s 21st Century plan for Health and Healthcare. His commitment is based on the following:
1) No Albertan will be denied access to medically necessary health services because of inability to pay. (The problem, Dave, is that we are being denied access already, and have been for some time. The Supreme Court of Canada says that access to a waiting list is not access to health care. And could you please define “a medically necessary service”. I’ve never seen that done before, so maybe you know something that I, and the rest of Albertans, would like to know).
2) Every Albertan will have access to the resources, education, and support necessary to achieve and maintain his or her best possible physical, social, and mental well being (This will be a true Utopia. I can hardly wait. The only trouble is, Dave, we first have to IDENTIFY the people at risk, and then we have to MOTIVATE them to access the resources, etc, etc. Then you have to PROVIDE the resources, keeping in mind that access to a waiting list is not an access to a resource; have we got the money for that? See funding---dealt with earlier).
3) All Albertans will have access to a high performing health care system that compares with the best health care systems in the world. (Now remember, Dave, access to a waiting list is not access to health care. And although our health care system compares to the best healthcare systems in the world, it does NOT compare favorably, as you well know from other dissertations on your web site. Further this has occurred largely under your watch. I think the question is how you are going to change this situation for the better).
Before winding this up, I should deal with two more innovative ideas that Dave Hancock seems to be fond of, that have not been mentioned in the news media to reduce emergency department waiting times.
1) I believe he supports the idea of a low intensity medical clinic near an emergency department to prevent “inappropriate” attendance to emergency departments by patients. My answer to this is three-fold. a) The number of inappropriate visits to our emergency departments have been steadily going down, and at present take up little time and resources in the emergency departments of Calgary. b) You would have to take resources from the community (doctors, nurses, etc) to staff these units. c) If there were adequate resources in the communities, patients would not go to the emergency departments and face six hour waits.
2) He definitely supports the “Full Capacity Protocol” that requires, within two hours or less, all stable admitted patients waiting in the ER for transfer to an in-hospital bed, should be transferred out of the emergency department to the appropriate ward, after a decision to admit has been made. Perfect; if only we had the “appropriate” beds required on the “appropriate” floor, and the appropriate” staff on the “appropriate” floor, to look after the patient “appropriately”. Come on, Dave. You and I both know that although this relieves congestion in the emergency department, more times than not, the transfers to in-patient beds will be “inappropriate”. This is the old “shell” game that I have referred to in the past that challenges the public and news media to find out (or guess) where our health care needs are being hidden. Already patients are being transferred to inappropriate beds by our “first bed available policy” and even when there is no bed available, end up being cared for in hallways. There is, as well, a small matter of having a physician attached and responsible for each and every patient admitted to an in-patient bed (and bringing in more nurses for the additional patient load). Very often our patients are in an emergency department bed, under the care of an emergency physician, because there are no hospital “staff” doctors to take on the care of the patient. On occasion our intensive care patients already “spill” into our medical ward beds “inappropriately” because we have run out of intensive care and/or cardiac care beds. So, please, Dave, don’t use the term “appropriate” when referring to our present Health Care System.
3) Since Dave Hancock suggests eliminating healthcare premiums (along with several other candidates) and recapturing the nearly one billion dollars derived there-from by increasing taxation in general, I should perhaps comment on this approach. There is no doubt that health care premiums are just another form of taxation, but it does continually inform the public that “health care” is not free. Since Mr. Hancock is in favor of “incentives” for healthy life styles (suggests tax-credits), I’m surprised he didn’t suggest eliminating premiums for those people and families with healthy life styles, and charging premiums for those with unhealthy life styles. Tax credits primarily benefit the wealthy. The bottom line is that Albertans are going to pay for their health services one way or the other, so it is a non issue.
I think, on the other hand, that it is “appropriate” to end here. If you want to delve deeper into Mr. Dave Hancock’s thoughts on Health care, he has much more on his web site. But I do advise you to approach it as you would a contract (If Dave gets to be premier, you’re going to be stuck with him), so read ALL the fine print.

Wednesday, November 22, 2006

Rutherford with Dinning on Healthcare

It would have been nice if Mr. Rutherford had done a bit of research on Mr. Dinning’s “track record” before having him on as a guest this morning. Mr. Dinning has been going around Alberta trumpeting his good performance, so one could have expected the same to be true on the Rutherford talk show this morning. Still, very little was said as to his performance as C.E.O. and Chairman of the Calgary Regional Health Authority. In fact, when one caller wished to bring up the subject, he was admonished for bringing up old issues. Come on, you can’t have it both ways, Mr. Rutherford. You can’t look at what you consider his “positives” without allowing for what some of us feel were his negatives.
Yes, Mr. Dinning and Mr. Klein started some welcome frugality in the Alberta Government, but along with the decrease in funding to our health care system must come the responsibility of those actions. Your caller had some good points; he couldn’t express himself well, but raising the question of the dramatic decrease in active treatment beds in Calgary during the 1990s, is a fair question. Edmonton didn’t follow this process and although their old General and Misercordia Hospitals were dinosaurs, they still stand and are being well used for transitional care and other medical needs. In Calgary, we dropped from 3.3 acute care beds per 1000 population to at present 1.7 beds per 1000 population. Look at how this actually changed during Mr. Dinning time as chair of the CHRA. and ask some questions. During his tenure, the population of Calgary was already sky-rocketing.
When the Calgary Region decided to sell the Holy Cross, all proposals were to comply with certain criteria. One of those criteria was that the property was not to be used for medical purposes, and that there would be no relationship between the Region and the prospective buyers. The caller was correct. Inside private interests bought the property and it is now being actively used for many medical purposes.
Mr. Dinning’s management and fiscal skills while he was Chairman of the Calgary region were not researched. If you look at the budgets during this time, he was continually short of money with his hand out to government. It was kind of an inside joke within the medical community “Well, at least we’ve got Jim and he’s got the inside track with Ralphy. If anyone can get money out of the government, he should be able to”. The point is, although he took the job of Chairperson because he had concerns about what was happening, and its impact on his mother (really!), he came up with no solutions and things have continued to go down hill. Now he says he supports the path we are on.
As I’ve said before, Mr. Dinning is very personable and very bright, but he is also the consummate politician. Mr. Rutherford, there is only one way to interview a politician, and that is to have the whole story and all the facts.

Ted Morton, Pluses and Minuses on Healthcare

Ted Morton has got one thing right for sure: Equal access to a waiting list, is not equal access to health care”. Has anyone seen a study of the death rate per thousand people on a cardiac wait list (risk list), compared to the death rate of a similar age group per thousand who are not on a cardiac “wait list”? If there is such a study, I have not seen it in the MSNM. The point is that waiting lists are, by definition, a group of people who have been identified as a group at risk and/or in need. But the identification of this group is only the preliminary step in a multi-staged system. Addressing the needs and risks of this group is the next essential step without which, the first step simply points at the inadequacies of the system. The Supreme Court of Canada has said as much!
For that matter, we are not even doing the first part right. Seventy five percent of the people at risk for heart disease and stroke in Alberta have either not been identified, or are not being treated adequately. If we truly believe in preventative medicine, doesn’t it make sense to identify this group and intervene before they are on a cardiac “intervention” wait list? Don’t get me started! I’ve ranted on that before, so let’s look further on what Mr. Ted Morton has to say.
It would seem that Mr. Morton recommends that Canada follow the European example of a blend of a private and public system. In his home page he recommends:
1) More opting out of insured services to the private sector.
(It should be pointed out that this has been going on for many years. The basic arrangement between physicians and the government is this type of an arrangement. Most physicians in Alberta are functioning as a private small business. The Alberta Medical Association and the government have negotiated the amount of money that would go to physician’s services on an annual basis-----basically contracting out physician’s services to the public at large. Almost all abortions in the Calgary region have been contracted out to the “abortion clinics” for the past eight years. There is nothing new in this policy; and the only money that is saved is the use of downgraded facilities, which may be appropriate, and an assembly line type of turnover. Don’t misunderstand me; I think this is a useful process, but standards of care must be carefully safeguarded.)
2) Attract more investors to build more medical facilities and purchase more diagnostic equipment. (If the government allows a private parallel system, the government/taxpayer will not have to spend one cent on recruiting investors. The health care pot in Alberta for “covered” services is over 10 billion dollars. If only 10% of the population obtains insurance, the incentive is considerable. In addition, the private sector will be actively doing research to find ways of delivering services more effectively and at a lower cost to invite more “contracting out” by the public sector.)
3) Affirm the freedom of Albertans to choose their health care. (You can pay for your pet’s operation and have it done in 24 hours, but you wait in a queue for weeks to have your child’s surgery. There is a problem with this picture!)
4) Allow doctors to work in both the public and private systems (This is particularly true for those physicians that are doing procedural medicine. Surgeons, cardiac interventionists, imaging and other diagnostics, etc, but it will do nothing for family physicians, internal medicine, neurology, psychiatry, etc. The only way these areas would be helped would be to have aggressive recruiting programs in other countries for both our private and public systems. By recruiting for two systems we would be more competitive on the world stage for the best physicians world wide).
5) Requires doctors to work a minimum number of hours per week in the public system. (Basically, I do not agree with this system. Brazil was doing this thirty-five years ago and the public felt it was a disaster. No-one is happy working where they do not wish to be, and if you’re not happy in your work place, you’ll do a crummy job. Surveys show that only five percent of Canadian physicians would prefer to work only in a private system. The majority prefer to work in both areas. Besides, making the public system compete in their treatment of their health care providers and the work environment, will “hold the governments “feet to the fire”, which is not the case now. As a consequence, there has been a steady drain of health providers to the U.S. and other countries).
Mr. Ted Morton also has included a speech on health care that he gave some months ago. Included are points that we have discussed above, but also included is his position that health care in Canada as it is cannot be sustained, and that Canada has been dropping in measures of health care outcomes. We do not “have the best health care in the world”, and rank in the bottom third of industrial nations when measuring outcomes. He mentions five tiers in our existing health care system, but left out the huge “tier” of patients that pay chiropractors and physiotherapists to treat their back pain, naturopaths to treat systemic symptoms, optometrists to treat their eye problems, etc. Many patients cannot afford these alternate services. So, Ted Morton, there is another tier you can add to your list.
Overall, from my perspective, Lyle Oberg and Ted Morton are the only ones thinking outside of the “Canada Healthcare Box” and consequently the only ones that may bring about change. My biggest criticism of Mr. Morton regarding health care is that he does not address, in any way whatsoever, an approach to preventative health and chronic disease. Perhaps he feels that saying too much opens one up to more criticism, but significant change means a more aggressive approach to getting the right treatment to the right patient at the right time, and from where I stand, this does not just mean the people on waiting lists. It includes the thousands of people who are at risk for diabetes, and those that are at risk for strokes and heart attacks. It includes an approach to the epidemic of obesity in general, childhood obesity in particular, and life styles that invite consumption of health care dollars and decrease quality of life. This is the true responsibility of government and its leaders-------identification, education, and intervention on a population basis. As individuals, once identified and provided with the information and available interventions, it is our responsibility to act appropriately. And we should have a choice in living up to those responsibilities.

Tuesday, November 21, 2006

Mr. Victor Doerksen Strikes Out on Healthcare

Mr. Victor Doerksen, the minister of Innovation and Science for the Alberta government in 2004, has very little to say about health care. He, of course, spouts the usual rhetoric about how important an issue it is, how everyone should have access to it regardless of their ability to pay, and his concern about sustainability. He presents his position under the following headings:
Determinants of health.
1).Enhance, by twenty five million dollars the “Alberta Child Health Benefit Program” to enable poor families to better access community child activities.
(Immunization is free and it would seem less that 50% of poor families access this resource).
2). Create a health research and innovation fund to focus on complimentary medicine outcomes. (Give me a break! There are at present about 3000 herbal or complimentary medicines out there at present; only about 300 of them have any hard research attached to them, so there are about 2,700 more to go. So far the 300 haven’t proved to be a savior of the health care system. What makes us think the others will be different. In the mean time people are using the “complimentary medicines AND services, and paying for them out of pocket, so it is actually saving the system money-----if there is more benefit than harm in them).
3) Long term funding through municipalities for better housing, homelessness, etc. (Obviously, Victor has bought into the idea that the determinants of health are poverty and poor education, rather than taking it a step farther and asking “What are the determinants of poverty, poor education, AND poor health. Need I say more?)
B. Sustainability
1) Establish a twenty five billion dollar Health Trust by 2016. (This seems to me to be just another way of pouring more money into the public system, and although that may help Alberta’s situation in the long term, the other provinces in Canada will not tolerate the loss of their health care workers to Alberta. The reality is more money needs to be put into the system in the short term, to shorten waiting lists, AND build up your fund. If you’re going to do it, you had better get with it before the federal government and the other provinces turn green with envy, and shut Alberta down like in the 1980s).
2). Work with health care workers to utilize the full capacity of the existing system------. (Mr. Doerksen, have you even been in a doctor’s office, an emergency ward, or a hospital ward, in the last five years?)
C. Refresh and build on the report of the 2001 “Report of the Premiers Advisory Council on Health”. (If the solutions are there, why hasn’t there been progress to date? That was five years ago and you have been in government and a cabinet minister during that time.)
All in all, Mr. Victor Doerksen has struck out on health care. Hopefully he has better ideas on other aspects of government concern.

Monday, November 20, 2006

Mr. Dinning, A Polished Politician's View on Healthcare

Knowing Jim Dinning somewhat through his and my committee work in the Calgary Region while he was the C.E.O. of the region, puts me at a bit of an advantage (and disadvantage, because I like the guy), in commenting on him as a prospective Alberta premier. There is no question that Mr. Jim Dinning is personable, charismatic, intelligent, and the consummate politician. In fact he is by far, in my opinion, the best politician of the “premiers to be”. The question is “Do Albertans want a politician as the next premier of Alberta?”.
I know, its a strange question, but I will elaborate. To win friends and influence people, tell them what they want to hear, and tell them what they already know. Don’t presume (in their presence) that you know more than they do. A good example of this is Mr. Dinning’s speech to the Calgary and area physicians. His opening statements to the group included: “Thanks for the opportunity to be here tonight and listen to a group---, and while I have some comments to make I’d prefer to hear some from you about health care----“. Then he carefully shows that he is not a neophyte in Healthcare, by stating that he was the Chair of the Board of the Health Region, and states that since then he has been a keen observer of the changes that have taken place in the health care arena. Brilliantly, he then goes on to tell the doctors what they already know:
1) In spite of numerous reports (Kirby, Mazankowski, Romanow) little has been actually done
2) I have learned that “healthcare reform has been more about talk and much less about action (actually, the efforts at reform that have taken place have devastated our previous well-functioning system)
3) Discussions about reform are almost impossible to have (because politicians need to get elected)
4) We’re quicker to come up with new plans than following through with what we started
5) The best ideas for what needs to be done to improve access come from people who actually work in the system (but have been consistently ignored because they have been viewed as a special interest group)
6) That people actually care deeply about health care
Wow, I want to vote for him right now. He certainly has insight, right? Well, maybe we should wait and see what else he has to say on the subject. You have to be careful with politicians. They have a habit of coming on as your best friend, but are nowhere to be found when you need them (mostly I’ve needed them to leave me alone!).
In his speech to the doctors he outlines five “plot lines”.
a) Get serious about health: Under this heading he raises the issue of preventative health, healthy life styles, etc. Nothing new here! We have been trying to do that for forty years. He does talk about establishing a Heritage Foundation to address issues in the first ten years of children’s lives (who can be against that?), but doesn’t say exactly how it would work. He talks about giving children a healthy start (sure sounds good, but will he be taking kids out of homes where people are poor?). After all, it seems less that 50% of these children are up to date on their immunizations. Will we have mandated nutritional classes for families with obese children, or home care nurses doing the grocery shopping for people on welfare? How much “child control” and “parent supervision” are we looking at here? Frankly I would have preferred a policy of taxing junk food, and taking junk food out of schools.
b) Forget about big plans----pick a few priorities and stick to them. (For sure, that is how to get things done). His choices for these priorities are primary health care delivery, an electronic health record, and new models of care for chronic illness. Now, how can you disagree with those three priorities, they lack the substance and detail as to how these priorities with decrease the cost of our publicly funded health care system, shorten wait times, or improve the quality of care, -----all thing that the average person is deeply concerned, but man they sound good! So far, efforts at primary health care reform have seriously shorted the availability of family doctors and primary care givers. What will you do differently? Although the electronic health record may improve some aspects of care and enable “tracking” of chronic disease, the cost of this system in the short term is increasing, and will continue to rise. Any benefits from tracking diseases will be far down the road and may be worth while, but it certainly is not a “here and now” cost benefit.
c) New models for care for chronic diseases. This, of course, means nothing to any of us. Although it has potential, as I have blogged, pertaining to the detection, registration, and targeting of people at risk, research in this area is in its early stages and is a long way from implementation.
3) Innovation----infusing more of it into our publicly funded health system
I think if I hear the word “innovation” one more time coming out of a politician’s mouth, I will be physically sick! The downturn in our health system in Canada, and the slipping of our world standings in health outcomes, started 15 years ago with the idea “we don’t need more money, we simply need more innovative ideas on how to use the money more wisely”. What in the world makes us think that our “innovative” ideas are any better now than they were 15 years ago? Statistics show that only a small percentage of innovative ideas are practical. On Mr. Dinning web site he mentions the success of the “Bone and Joint” pilot project. Jim, to my knowledge, millions of dollars were put into this project, which only underscores the fact that huge amounts of money are going to be needed to shorten our long waiting lists. How does that address our concerns about the sustainability of our publicly funded healthcare system?
4) Increase our supply of health care providers and get them to where they are needed.
On Mr. Dinning’s web site he addresses this issue by first stating that there is this crises in health care workers(again, a fact that we all appreciate) but then sings the same old tired tune of training more, bringing in more foreign doctors and assisting in student loans. Not a very exciting solution; in fact it is no solution at all. Jim, first you have to recruit students into the health care fields, then after you train them, you have to KEEP them. How do you propose that we prevent them from going to the U.S. after graduation? We have been actively recruiting qualified foreign physicians. In spite of half of Sask. physicians being foreign trained, we are still falling far behind----but you know all this, don’t you! Try to focus, as you suggest we all do, and actually suggest a PLAN as you recommend.
5) Find practical ways of containing cost increases (now we have arrived at the crux of the problem, sustainability). Mr. Dinning’s only suggestions in this area are: a) Micromanagement, and b) Examine the use of an independent, arm’s length body to review and assess new treatments and services as part of the process for adding these to the list of things under public health care. Well, to me micromanagement usually means more money to administration, and less to patient care. The “arms length” review body to assess appropriateness for healthcare coverage is nothing new; but what in heavens name does “arms length” mean? Does this mean lawyers, accountants, and politicians? I made a similar suggestion to Mr. Don Ford, Health Care Policy adviser to the Klein government, in a presentation submitted in Feb/1998, but I suggested a “hands-on” group consisting of doctors, nurses, pharmacists, chiropractors, physiotherapists, and tax payers. The “arms length” group, Price Waterhouse, suggested in the 1990s that all the hospital boards in the Calgary Region be brought under one “Arms Length Board” which agreed to their proposal to sell the Grace and Rockyview Hospitals, and blow up the General Hospital. Can Calgary survive another “arms length” provincial body looking at health care?
I have always said and still maintain that no government can provide infinite services without having infinite resources, and the reality is, that in spite of very ingenious tax methodologies, governments do, in fact, have limited resources.
So, that’s it folks. Mr. Dinning, like Mr. Oberg, has more knowledge of our health care system than the other candidates, but I’m afraid has no new solutions. In fact, by not thinking outside of the “Canada Health Care Box”, Mr. Dinning takes away many potential alternatives. On the other hand, keep in mind I have stated that Mr. Dinning is an extremely “bright” guy, and the most “polished” of the candidates (I apologize for the attempt at humor in such a serious dissertation), and it certainly wouldn’t be the first time that a political candidate vaulted themselves into office by supporting our “Universal Health Care System”. Could this why he is pushing the status quo? Perhaps I’m just being paranoid. Pass me my haldol.

Sunday, November 19, 2006

Abuse of Nurses and Staff

It would seem that our health care system in Canada (if Calgary is any indication) is getting weirder by the day! The Calgary Herald, Sunday, Nov. 19/06 edition headlines read “Abusive Patients Attack Nurses”. Now, as a family physician with more than forty years of practice experience, I can assure you that this is not new and is not a surprise. The article relates that documentation indicates a dramatic rise in both verbal and aggressive behavior toward healthcare providers, in particular, nurses. The article gives the example of a patient suffering from a drug overdose, being admitted to a cardiac unit for monitoring, becoming very aggressive and physically abusive to the nurses after two days. Here is a news flash! This is to be expected. People going into withdrawal frequently become agitated and abusive; that is the medical reality. The real question is “Was there an appropriate place, with the appropriate staff available, for appropriate transfer”? Why was the patient on a cardiac unit after two days? Did he really still need cardiac monitoring, or was there simply not an appropriate bed available? Many times in my practice patients for medical reasons are admitted to a medical bed for observation, and when the appropriate time came for transfer to a mental health bed, no bed was available. Consequently, a mental health patient ends up in a medical bed, being treated by a medical nurse (in this case, a cardiac bed and cardiac nurse), when they should be in a psychiatric facility treated by staff familiar with psychiatric and drug withdrawal problems.
This problem has been ongoing for many years and continues to get worse. Since the dramatic downturn in available hospital beds, patients get admitted (from the emergency departments) to the beds that are available, not necessarily to the department that is most appropriate. If there are beds available and the emergency department is jammed up, what is to be done? The staff use the beds available and the staff available, even though it may mean a medical patient ends up on a surgical unit, or even worse, a psychiatric patient ends up on a medical unit (the overdose scenario is typical).
I am sure, as the article implies, there is an increase in frustration on the part of patients who perceive that their needs are not being met, and this leads to increased acting out and abuse. When patients are suffering and in pain, it is not surprising that these patients become more difficult to manage. Nurses have always been, and are aware of this fact, and have dealt with it appropriately. Aggressive personalities often come to light when people are ill, or coming out of an anesthetic, but this isn’t a new phenomenon. Could our sense of entitlement as a patient be having an effect, or are there genuine deficiencies? Probably both are factors. But I think that the basic problem is not a “patient” behavior problem (not making excuses for abusive behavior!). Let us look at the actual statistics and what can be gleaned by the article.
Reported incidents have doubled at the Peter Lougheed Hospital in the last year. At the Foothills Hospital, complaints went from 25 in 2004, to 79 in 2005, to 112 already this year. Other hospitals have shown similar rises (It should be pointed out that an “incident” includes any situation where the nurse feels unsafe, or when the nurse feels the patient has been put at risk). Wendy Brigham, president of the Alberta Nurses Association local 121 at the Rockyview Hospital says “Nurses are getting really frustrated. They’re finally taking the time to document what’s going on”. This statement says it all, if we look at it closely.
Are they frustrated at the patient’s behavior (which they likely fully understand from a professional and intellectual perspective), or is it that their general stress and frustration level relative from a difficult work environment, has reached a point that their tolerance for bad behavior is now almost non-existent? As innovation and other changes have occurred over the past 15 years, nurses and other health care providers have simply put their heads down and worked harder and harder. Some of you may have read a previous blog where I mentioned that, during my recent visit to the recovery room of a local hospital, I was amazed at the intensity of care level, and the looks of stress on the faces of all the nurses. Perhaps the nurses have simply reached their level of endurance; perhaps more and more have simply reached that point of saying in writing “I can’t cope anymore with these conditions, something has to be done”. And it is about time. So they are now taking the time to report what has been going on. Perhaps the reporting is not so much a reflection of the “bad behavior” increase of patients, as much as the level of exhaustion of our nurses. We all tolerate untoward behavior better when we are rested and feel good in our jobs. Feeling you are doing a good job, getting “kudos” for the job you are doing, and having some control of your responsibilities in your day to day work place environment, goes a long way to putting up with your job “incidents”. But if at the end of every day you go home with the feeling that you didn’t have the time to deal with the responsibilities you’re given, deal with “patient at risk” situations, feel helpless from lack of resources and staff, and have the ongoing feeling that you are unappreciated, at some point, the frustration level must become unbearable.
The most incredible aspect of this situation has been the response of the Region. Their response to long waiting room times in out emergency departments is to hire an emergency room social worker. Their response, apparently, to the shortage of nurses and the increase of (reported) abusive incidence in our hospitals, is to hire 150 more security staff. Can security staff really take on nursing duties? Is this an “expanded role” of health care providers as suggested by the “premiers-to-be” of the Conservative Party of Alberta?
The article in the Herald states that the Calgary Region intends to aggressively hire the new graduates from our nursing schools. Great! But good luck! You not only have to hire them, you have to retain them. High stress levels in nurses work place is not going to help in the face of a world shortage of qualified nurses and aging demographics in the nursing profession and the population at large. Are we as nation going to start addressing the core problems, rather than the symptoms, or are we going to continue to simply insert more fingers in our Universal health care dyke, while the healthcare needs continue to rise?

Healthcare Pep-talk by Mr. Ed Stelmach

The only thing that I could find on Mr. Ed. Stelmach’s website with regards to health care, was his “pep” talk under the heading “A commitment to a publicly funded health system that works for all Albertans” I guess the mother’s milk statement has worked so well for federal politicians over the last twenty years that there is no reason to believe it won’t work here and now in Alberta. To save you, the political healthcare keeners from having to go to his web site, I will include it, verbatim, below.
“I envision a health care system that is efficient from a patient’s perspective. An efficient healthcare system doesn’t only mean saving money. We must be focused on the patient and put their needs first. Governments must work with health regions and health care professionals to find solutions together and develop incentives that improve the system and improve the health outcomes for Albertans. I believe we have the answers.
Our health care professionals are knowledgeable, dedicated, motivated, and most importantly, care deeply about meeting the health care needs of patients. We have seen successes, with the hip and knee projects, with the primary care centres, and soon, with an expanded scope of practice for more health care professionals. There is still work to be done; however, I believe our public funded system is up to the challenge”.
Well, thank you for the above “pep-talk” and vote of confidence, but I, as a health care professional, do not share your enthusiasm. Many outcome measurements show Canada falling far behind other industrial nations of the world, yet you state that we have the answers. I’m not sure you heard the questions: How do we address the increasing cost in our tax funded monopolistic healthcare system, how do we deal with ever lengthening waiting lists (risk lists), how do we deal with the dramatic lack of human resources in providing the needs of Albertans, and so on? The hip and knee pilot project you mention, required the input of additional tens of millions of dollars to bring about a small dent in the number of people waiting for joint replacement. How does this address sustainability? I suppose, when you speak of primary care centres, you are referring to such clinics as the Calgary 8th and 8th clinic, the South Calgary Clinic, the Okotoks Clinic, and other regionally run and heavily subsidized clinics. Here is a news flash! Before the devastating cut backs of the nineties, Calgary had many community medical clinics that provided equivalent services to the community, and none of them were subsidized. So how do you see these heavily tax-payer funded community funded medical clinics being the answer to sustainability of our health care system? Sorry, Ed. but your position seems to be “cheer everybody on and good things will happen”, and frankly, Ed., I find that bordering on administrative dereliction of duty. To have a “vision” one must take off the blindfold.

Saturday, November 18, 2006

Mr. Mark Norris, The Healthcare Micro-manager.

Mr. Mark Norris likes to preface many subjects with “this is a very complex subject”. It is little surprise then, for him to introduce the issue of “health and wellness” with the statement: “Over the years the system has evolved, become complex, expensive, and difficult to understand. He goes on to admit there has been a significant increase in cost per capita, but from what I can decipher, his answer is primarily an increase in micromanagement. Isn’t this just putting money into administration, and taking it away from the frontline caregivers? But let us see where he is going with this, in more detail.
1) Ensure the partners in the health-care system are accountable for health and financial outcomes. a) Review management systems (does this mean we will have managers of managers? I think we have lots of that already).
2) Ensure health-care delivery standards will be set, measured, and met (sorry, this should have been done many years ago before the standards had slipped to their present level). He recommends more a) discussion (fifteen years of it isn’t enough?) b) review of the electronic system as per patient confidentiality (that will certainly help sustainability). c) Establish a peer review process for new technology and drugs as to what is cost effective (I would suggest that this has been going on continually already, but behind closed doors; now if he had said a professional body should be structured to do this, with public overview and accountability----------). d) Set up a “group purchasing” model to improve the purchasing power of the entire system (this has already been done in a major way by the establishment of large health regions. The most significant area that would benefit would be in the area of pharmaceuticals, and this would be best done on a national basis. Unfortunately, the federal government is not likely to take on the area of medicine with the sharpest rising costs).
3) Ensure access to health care is maintained for all Albertans a) Further extend the diagnostic and treatment centre clinic model that is working effectively in other areas (is this the same model that practitioners had before cut backs in the 1990s that provided comprehensive care without subsidization from the Regional Health Authorities, or the models that are now being run by the same Authorities, providing the same services, but are being heavily subsidized by the Region?). b) Consider locating medi-centers near major emergency wards (and where will the doctors come from to staff the place. I think improving the care in the communities, rather than taking doctors out of the communities, serves the needs of patients better). c) Review the 3.5 billion capital plan for health care to ensure the right facility is being built in the right place (Mark, this should have been done ten to fifteen years ago. The problem now is to provide people/power for the facilities that are being planned, and not one of your proposals addresses this dilemma. Almost any physical structure that will accommodate patients and health care personnel would be welcome at this point in time).
So that’s it folks. Our premier-in-waiting, Mr. Mark Norris, will review, analyze, study, supervise, and in general, manage the managers better, with a view to improving the efficiencies of our system. Nice try, but no cigar.

Friday, November 17, 2006

Dr. Lyle Oberg on Health Care, Some Good Suggestions.

I suppose the fact that Dr. Lyle Oberg was a busy family doctor in the Brooks area of Alberta, does give him a distinct advantage in discussions on health care. He correctly identifies the problems with regard to the sustainability of health care in Alberta, quoting budget increases from 3.3 billion in 1994 to 10 billion at present. This is reflected also in the proportionate increases in the relative increase that health care takes in the provincial budget expenditures. As the population ages with the relative proportional increase in the geriatric population, we can expect health care spending to continue to grow out of proportion to taxation revenues, inflation, etc.
Dr. Oberg presents his “vision” in a five point frame of reference.
1) Guaranteed access.
Since not having access means not having health care, this is pretty basic. Guaranteed wait times have been discussed for some time now, and the principle has been approved by both the Canadian Medical Association and the Alberta Medical Association. At present I have seen little movement on the part of governments to introduce legislation to this effect. Personally, I think it is one of those “feel good” solutions that are almost impossible to put in place. First, there must be a recognized authority on specific wait times that would be appropriate. I recall seeing a rough draft of such a recommendation that said forty eight hours was an acceptable wait time for patients with a fractured hip. There are excellent studies in the literature that show increased morbidity and mortality after waiting times of twenty four hours, for a fractured hip, are surpassed. The second problem with guaranteed wait times would be the complexity of monitoring and implementing such a system. The third problem is that provincial governments do not have the capacity (either facility wise or personnel wise) to meet even semi-reasonable wait times. Problem four is, since we don’t have the capacity, where do we send the people who require a treatment and have surpassed their guaranteed waiting time? Will the government be penalized in any way for not meeting their “guaranteed” waiting time? How do you punish a provincial government? Do we want Ottawa to do it by with-holding transfer monies? If so, there will have to be Federal and universal Provincial agreement on both, what comprises a guaranteed procedure under the Canada Health Act, and what the time frame should be for any and every procedure that is guaranteed.. Dr. Oberg suggests that the accountability will rest with Albertans in provincial elections. Perhaps that is the simplest solution.
2) Public guarantees.
Dr. Oberg recommends that doctors be allowed to practice in both the public and in a private parallel system. He doesn’t spell it out, but this would infer that he would approve of patients being able to apply for health care insurance, and would allow health care insurance companies to be active in Alberta. This, in itself, is a step forward. This will push the public system to identify the procedures they cover and do not cover, and the time frame that they are prepared to back. The public will demand it in order for them to decide as to whether they spend money on additional health coverage. The longer the waiting lists, the more privately insured people there will be (thus shortening the waiting lists); the shorter the waiting lists, the fewer the people signing up for private insurance. Dr. Oberg’s idea of forcing doctors to work seventy five percent of their time in the public sector before they can work in the public sector is simply not workable. Administration of such a system would be a nightmare. What are we, as practitioners, to do; I will be working in the public sector from January to September inclusive, but won’t be available to the public sector in October and November because I’ll be in the private sector? I don’t think you have thought this one out clearly Lyle. People don’t like being forced into situations that they do not wish to be. Studies show that only five percent of physicians would want to practice in the private sector. Likely this group could be augmented with active recruiting of Canadian physicians who have immigrated to the U.S. over the past fifteen years. The majority of Canadian physicians have indicated a preference for staying in the public system. If our governments treat them right, there should be no problem allowing physicians practice where they enjoy their work. The majority of physicians practice medicine because they enjoy the work!
3) Enhancing patient choice
Choice should be a “given” in a democratic country, but with privilege, there should be responsibilities. Studies have shown that when the patients have to make choices, they tend to inform themselves as to the pros and cons of their potential choices. The possibility of a parallel insurance system will, of itself, be a stimulus for people to look at cost effectiveness. It will bring about more investigative searching on the part of patients, to look at various forms of interventions and preventative therapies and their benefits (the private system usually gives premium breaks to patients with healthy life styles, the public system will have to look at alternate ways to encourage and motivate healthy life styles). It brings alternate care providers into the equation (homeopaths, chiropractors, podiatrists, etc.) without forcing the patient to pay out of pocket, and at the same time, not be a burden on tax dollars. Some European health care systems have included some of these services under the public umbrella, as we in Alberta have done to some degree with chiropractic and podiatry.
Basically, the increase in patient choice must take place in a more free market environment if it is not to be a drain on the provincial government’s tax-payer funded budget.
4) Proactive solutions
Here again, one of our candidates brings up preventative medicine and promoting healthy life styles; however he distinguishes himself from the rest with some important methodology. He correctly points out that managing chronic disease is the key to preventative medicine’s cost effectiveness. In doing this we need to think of chronic disease in a broad sense; not just those people who are symptomatic such as patients with arthritis, diabetes, asthma, etc. The greatest benefit would be to capture those people that are asymptomatic and before they experience the complications of their chronic disease. Hypertensives, the obese, the hypercholesteremics, the smokers, etc, fall into this category. This group of asymptomatic chronic disease patients need to be involved in a very direct way to change their life styles and intervene when appropriate. With the help of electronic technologies, registration and tracking systems for those people at risk could potentially be a real winner, treating the right patient at the right time with the appropriate intervention. (I believe that money spent on generic T.V. commercials directed to the public at large is money poorly spent). To my knowledge, Alberta, at present, is investing millions of dollars in such tracking pilot projects in chronic disease. This is one of the few bright lights in preventative health since immunization programs were introduced. I encourage strong support for these preventative pilot projects and trust this is the area that Dr. Oberg is referring to.
5) Equitably Sharing Costs
Health care premiums are simply another tax, so I agree with those candidates, to some degree, that they should be eliminated. If the premium system were implemented in a different way, there could be some advantages. What if there were variable premiums, dependant on life styles? What if your premiums were determined by B.M.I., blood pressure, smoking, activity levels, etc. (and don’t give me the garbage of taxing the ill; it is RARE that normal blood pressures cannot be achieved with proper intervention). Money seems to be a universal incentive, and cost a universal disincentive. Note the use of fines for speeding, not using seat belts, wearing helmets, and more recently in Calgary, for spitting on the sidewalk. Let’s get consistent.
So, Dr. Lyle Oberg, you have done the best of the bunch in the area of health care. I guess my concern is that you have been in cabinet many years, and there is little evidence of your input. As premier, will you have the courage and determination to move from the present point of stagnation (and back-sliding from world standings perspectives), to a more truly innovative, thinking “outside of the Canada Health Care Box” position?

Thursday, November 16, 2006

Mr. Gary McPherson's Vision of Healthcare in Canada

For completeness and fairness sake, I will continue this dissection of the “vision” of Alberta’s “would be premiers” by critiquing the information obtained from their home web sites. Keep in mind, this information has been compiled by the candidate and, I would presume, their advisers, with ample time to think, ponder, pontificate, obfuscate, and in general confuse the reader. Is anyone out there good at de-coding?
Today we will look at Mr. McPherson’s “vision” and solutions for healthcare in Canada. He states that heath care in Canada needs to be sustainable, and does not believe that this should be done by bringing in “private” medicine, because this would amount to a “two tiered” system. I’m sorry, Gary, but we have many tiers to our health care system at present. One of my patients recently returned from the U. S., where he had life saving surgery done, that was not available in Canada. This “two tiered” boogy-man is getting tiresome. We have multi-tiers, at present, in our health care system. It would also seem that Mr. McPherson believes that “expanding the role of the current department of health to include more opportunities for alternate treatment methods and healthy living initiatives that will help to ensure that the medical care system is only accessed when it is absolutely necessary to do so”. Wow, that sounds good, except it implies certain things. It implies that people are using the system when they don’t need to. The evidence shows that people are actually using the system appropriately. Who would sit in an emergency department for eight hours if they didn’t genuinely feel they needed help. And the statistics back this up. Check it out Gary! Besides, wasn’t the system brought in so patients didn’t need to “worry” and make choices between food and medical care? Now their choices are wait on lists or ignore your problems or concerns. Both amount to “no care”.
The healthy living initiatives sounds good, but this has been pushed for forty years and we are failing miserably. Only 25% of the people with high blood pressure are being treated to target. Similar statistics apply to people with high cholesterol. The Saskatoon Star Phoenix newspaper recently reported a study that showed 95% of children in most average and well to do communities were up to date on their immunizations, but there still were “poor” communities in Saskatoon, where only 46% of the children were up to date on their immunizations. Now, immunization programs are the most cost effective preventative measures in medicine, and have been around for more than fifty years and ARE and HAVE BEEN FREE. Please don’t tell me that these parents don’t KNOW that, or that smoking is BAD, or that they shouldn’t eat junk food, etc. The problem is MOTIVATION. How are you going to get people to be motivated to live healthy life styles, Gary? What is your PLAN?
Mr. McPherson’s final assumption and implication is that other providers offer cheaper services than a family doctor for an equivalent service, and by involving these providers more opportunity, we could reduce costs to the health care system. I suppose that is true if we keep them OUTSIDE of the public health care system; but it seems Gary means to bring them into the public system! Let us look at some of these opportunities:
1) Maternity care and delivery
Midwives $2500.oo to 5,000.oo
Family Physician Approximately $1000.oo
2) Office visits
Family Physician Approximately $30.oo
Podiatrist App. $40.oo to $45.oo
Chiropractor App. $30.oo to $40.oo
Acupuncture App. $40.oo to $50.oo
Physiotherapy App. $40.oo to $50.oo
Holistic physician outside of Alberta Health care---- $300.oo to $325.oo per hour.
The bottom line, Mr. McPherson, is that a good family doctor, doing comprehensive continuing care, is the most cost effective practitioner we have, so we had better come up with ways of restoring that part of our health care system. The Americans recognized this twenty years ago, and aggressively recruited our family doctors. In Canada, we are just beginning to see their value. Other care givers are saving the system money at present because, for the most part, they are outside of the system, and people fork money out of their pocket to obtain these services. Our long waiting times for traditional medical services actually pushes people outside of the system, and saves the system money. Of course, I am referring to those that can afford to pay for these services (it’s another tier of health care).
Tomorrow we will look at Dr. Lyle Oberg’s “vision” and contribution to the health care debate.

Tuesday, November 14, 2006

More Questions and Answers on Healthcare

I did warn you that these entries dissecting our “would be” Alberta premiers positions on health care would be boring! Nevertheless the pursuit of the truth has no bounds, so we will continue. Another question put to our conservative leadership candidates had to do with the health professions legislation and expanded scope of practice, including the ability of pharmacists to prescribe. Good question, especially since I have recently heard that this is, in fact, already a “fait et complete” against the wishes of the Alberta Medical Association. Generally, there seemed to be an agreement among the candidates that everyone should practice “to the full extent of their training and capability”, whatever that means. Isn’t this the very essence of the discussions and the concerns of the AMA------that pharmacists are not trained to diagnose and this opens the door to that activity? Mr. Hancock included “and take responsibility”, Mr. Dinning assured the questioner that this would only happen after all concerned parties had their concerns addressed over time (doesn’t sound like that is happening), and Mr. McPherson emphasized the collaboration that needed to exist between the family physician and pharmacist.
So here is the medical reality. Many of the family physicians I have talked to are not prepared to “supervise” and take responsibility for pharmacists prescribing for their patients. In a court of law, the person who is most adequately trained in a “collaborative” relationship bears the major responsibility for outcomes, and pharmacists are not trained in diagnostics. Further, collaboration takes time, and family doctors do not get paid on a time basis like lawyers and other workers. We are already spending 20 to 30 percent of our time doing things for which we have no ability to charge (including “collaborating”). With the advent of other “advisers” in health care over the past few years and the many people involved in prescribing (various specialist) and people recommending medications (herbal remedies, over the counter medications, etc), it is already a mine field trying to monitor patients’ pharmaceutical intake. That is not to say that working with pharmacists and other health care workers isn’t essential, but overlapping responsibilities is potentially confusing and ultimately, the responsibility for untoward events will fall on the family doctor. Pharmacists should be allowed to have lea-way in repeating medications for conditions that have already been diagnosed and need ongoing management; they are essential in assisting physicians where drug interactions are a possibility, but diagnosing, at this point in time, will further alienate family physicians.
The question of electronic health records was supported by all the candidates but I must say that only Mr. Norris seemed to have significant reservations regarding cost, confidentiality, etc. There is no question that the electronic health record will have a huge positive impact on “tracking” people at risk, outcomes, etc, and possibly decreasing certain investigations and costs for the system, but there is an increase cost to the practitioner. At present some of these costs are offset by an “initiation” program, however, this program will not be continued indefinitely, but the added cost to running a practitioner’s “electronic” office will. My own personal physician has had his office computerized for many years, and our discussions invariably involve him looking at the computer screen 95% of the time. What happened to “looking the patient in the eye”, or “relating” to the patient? It’s kind of a “cold” environment, if you ask me. Is it any wonder that people feel that “holistic” doctors “care” more?
The last question asked by the Calgary medical Association was “What do you see as the biggest problem in healthcare in Alberta today, and as premier, how would you deal with it?”. Being such an important question I will consider each candidates answers separately.
1) Mr. McPherson.
a) Waiting lists b) Manpower shortages c) Lack of planning to ensure sustainability. His suggested solutions: Using personnel more effectively, and creating a “culture of health”. My response: Good luck on the culture of health “thing”. Furthermore, I recently had occasion to be in a recovery room at one of Calgary’s hospitals. My Lord, it was like an intensive care unit of ten years ago but with a lot more patients. The nurses should have been on roller skates. They all looked like they were in shock from their stress levels. Might I suggest that the caregivers within the system are already stretched to their limit? You may want to start rewarding the people in the system, like paying the nurses in that recovery room $100,000.oo a year or more.
2) Mr. Oberg
From the Vital Signs publication: “Without a doubt, the biggest challenge we face today in healthcare is the need to slow the rate of growth in the overall healthcare budget to within a reasonable range of population growth and inflation”. Not included in his response is the part “and how would you deal with it? Now I know that he has stated that he would allow doctors to work in the private system 25% of the time in an attempt to better utilize physicians and shorten wait times. Would the government pay the physicians for their work in the private system? If so, wouldn’t the cost go up, based on the increase of work alone? If the government contracted the work out, the cost would be borne by the taxpayer anyway. It would seem that a private insurance system would be required to actually decrease the cost to the average tax payer. To my recollection, Ted Morton is the only candidate that actually has stated this as his position.
3) Mr. Hancock
This premier hopeful correctly (in my view) again raises the problem of sustainability. Unfortunately he believes this can be done though healthier lifestyles (ideologically correct, but have been failing over the past forty years). He does offer some suggestions: a) offering tax incentives for healthy lifestyle choices (unfortunately the greatest demand is disproportionately by those in a “no or low” income tax bracket), b) Instituting a province wide ban on smoking in public places (will help in 20 years but may actually cost the government loss of tobacco tax revenue in the short term--------if it does anything at all to decrease consumption). c) Increasing taxes on tobacco and alcohol (add junk food to the list please), and d) Implement measures that are known to reduce avoidable trauma (protect us from ourselves). Well, at least Mr. Hancock attempted to answer the question.
Mr. Dinning
He seemed to say that although the focus was on “cost” he didn’t think that was the problem. He said “health” was the problem, and then got into the “prevention thing” and made no suggestions as what to implement, from a government perspective, for the people to have better “health”.
Mr. Norris
In the Vital signs publication he states that he believes that accessibility of health services remains at the forefront of challenges. He seems to think that increasing the efficiency of the system by addressing “bottlenecks” is the answer. His second point was to expand priorities rather than the entire system. From where I sit, it appears to me there are expansion needs in all aspects of the system. Is he referring to the possibility of actually defining what should be covered under the Canada Health Act and expanding those items, and de-listing other services? Seems like an obtuse way of proposing this. He does mention units that would accommodate patients that presently are “bed blockers” in acute care facilities (I presume he is talking about transitional care units, rehab units, palliative care units, etc. but we have been doing that for at least ten years now). I agree. We could be doing more of that, providing these units are adequately staffed and equipped (which at present, they are not), but it does have the potential of putting the patient in the appropriate environment and allows cost sharing on the part of the patient and the facilities (from the public’s perspective it means they have to pay out of pocket money; is that what the public wants?).
This concludes some excellent questions put forward by the Calgary and Region Physicians association, to the prospective conservative leaders of Alberta. Your job is to judge them on the healthcare issues by their answers. From my perspective, I see nothing new, and certainly no “vision”. Over the next day or two I will comment on what I could find on their respective web sites. So, if you are an insomniac or have a strong inclination for suffering, tune in for more on “Where I stand on Health Care” by Alberta’s “Conservative Leaders to Be”.

Monday, November 13, 2006

Conservative Leadership Hopefulls and Health Care Solutions

Apparently, health care is no longer the number one concern of Albertans; so for those who have been sitting in traffic for the past hour, are having trouble finding housing and shelter, etc., save yourselves some time and don’t read this entry-----boring! But for those of you who have been waiting in the emergency rooms, hospital hallways, on waiting lists, and, well, even if you are over 65, it may be worth while reading. Still boring, but factual stuff always is. What a pain it was for me to try to glean factual information from all the political double-speak.
It has been two weeks since I sent some questions to the “premiers to be” of Alberta and have two responses to date; Mark Norris sent a computer generated response thanking me for my “comments” and Gary McPherson actually sent me his approach would be to involve more disciplines as providers, and then asked me what I thought of the idea! Good for you, Gary. At least you put some personal effort into a real response and asked a doctor for an opinion; a novel approach for a politician. I guess I shouldn’t feel snubbed, though, since (from what I can determine) the Alberta Medical Association asked the candidates a number of excellent questions, and only Dave Hancock posted the questions and answers on his website. The Calgary and District Medical Association also posed several excellent questions, and from what I can tell, only McPherson, Hancock, Oberg, Dinning and Norris gave “answers” that were subsequently printed in the Associations’ news letter “Vital Signs”. So, having little or no response myself from the candidates (I’m just a Conservative voting member), I searched their Web home pages for answers to my questions (and the questions of others) on their position on Health Care in Canada, and in particular, Alberta. This is what I found and didn’t find. First, from the Calgary Region doctors:
1) “There currently is a physician shortage in Alberta which is expected to get worse over the next five years. As premier, what steps would you take to educate, recruit, and retain the physicians needed to care for Albertans”? This is a very good question and here are some of the answers given. McPherson, Oberg, Hancock, Dinning and Norris all said they would increase, or work at increasing, or fund additional spaces in medical schools. Please note that to train a family doctor takes EIGHT years, so this is unlikely to improve the situation over the next FIVE years. Mr. Dinning and Mr. Norris improved their answers by suggesting some modifications to the residency programs in Canada. Certainly, increasing the available residency programs in Canada may prevent our medical graduates being forced to go to other countries to obtain their residencies (and then not be eligible to return to Canada); however if these additional spaces are filled with “paying” foreign graduates, our boys and girls will be no better off. Still, it will shorten the time line for improving our doctor to patient ratios. My understanding is that there is, apparently, in some areas, a shortage of physicians prepared to teach, which of course makes increasing residency positions quite difficult. McPherson, Hancock, Dinning, and Norris all mentioned the recruitment of foreign doctors. Mr. Dinning attempted to do them one better by mentioning recruitment “nationally”. Well here is a news flash, folks. We have been doing this for many years and it has only gained us the ill will of other provinces and other countries. We continue to fall far behind in spite of a significant effort at recruitment for at least twenty five years. The question was what STEPS you would take to recruit. It is estimated that at present a full 50% of Saskatchewan’s physician force has been imported! The well of reasonably qualified international candidates is drying up.
Startling in its absence is the candidate’s response to the question of the “retention” of physicians. Not one of the candidates made one suggestion to address this problem. It seems to me that if we train physicians, only to have them leave the country after graduation, we have accomplished nothing! Sort of like poring water into a bucket with a large hole in the bottom!
The second part of the first question had to do with the recommendation from Alberta Learning that interest free status should be given to learners completing a residency program, and that repayment requirements for student loans not be initiated until residency requirements have been met. All of the candidates mentioned above thought this was a great idea. This is really a nice thought, and encourages students to undertake residency programs that may be longer and not have to worry about interest on student loans and repayment plans until they actually have a license and get a “real” job. The problem is, in medicine, we don’t need more super specialists; we need more generalists. We already have a shortage of family physicians and enabling students in medicine financial incentives to specialize will aggravate this problem. Certainly I would have thought seriously of continuing on in a specialty if I had not had financial pressures to get on with getting a job. I’m not saying that this idea isn’t great for some areas of learning. I’m just suggesting that in medicine it may be counter-productive and aggravate an existing problem.
2) What steps would you take to ensure the survival of the family practice doctor in Alberta? Wow, another great question; especially since encouraging them to specialize with interest free loans and delayed payment schedules will encourage specialization. Although many other professions and trades have been able to keep up with the inflationary cost of living in Alberta, family doctors are tied to a fee schedule that is rigid, and actually is punitive to those family physicians doing comprehensive continuing care in their practices. Mr. McPherson thought that perhaps interest free loans and tax incentives for new graduates would be helpful. It would seem he didn’t realize that it was the older physicians who were doing the less lucrative work (geriatrics, palliative care, etc) that were giving up their practices. The new graduates were finding niches that were far more lucrative (walk-in clinics, hospitalists, locum tenens, no one in the practice over 60 years of age, etc). He also thought that some of the ancillary medical people (chiropractors, holistic docs, naturopaths, etc) could take over more of the duties of family doctors. He apparently doesn’t realize that on an hourly basis, these practitioners are much more costly than traditional family doctors. Mr. Hancock said much, but primarily seemed to be pushing the concept of primary care networks, which I have commented on in previous blogs. He again thought there should be more use of alternate providers and emphasis on prevention. In short, it would seem (since he had no ideas as to help the family physician situation), he acknowledged, and perhaps even welcomed, the decline in the numbers of family physicians as a “cost savings” measure. Mr. Dinning referred to “primary care networks” and the present “funding” in place to help computerize their offices may be an incentive, but basically his position was that it was too bad family physicians were declining in numbers, and the issue was really between the AMA and the provincial government during negotiations (I guess he is inferring that money may be a root cause). Nothing new there! Mr. Norris enlightened us with the fact that negotiations are presently going on between the AMA and the government and he is sure that an agreement will be reached soon. Wow, that sure inspired me to be a family doctor! He did suggest that there was a NEED to look at ways to encourage medical grads to choose family medicine. Sorry, I thought the question was “how would you do that?”. Mr. Oberg actually came up with a very novel and unique suggestion “Increase the fee schedule for family physicians doing comprehensive care”. With that revelation I will close today’s mind boggling discussions on the future of health care in Alberta as seen by our “Conservative Leader Want-to-be’s” and premier hopefuls. I will continue their responses to more questions over the next few days. And of course, if any of their representatives wish to clarify, agree, disagree, etc. you are invited to comment.