What's Wrong with Healthcare?

Thinking inside and outside of the healthcare box. After 41 years of family practice, what's happened to Canada's healthcare system?

Sunday, March 25, 2007

Physician Assistants

At least the health care article written for the Calgary Herald, Mar/25, by James Ferrabee, was informative. He describes how much of the primary care in the U.S. is being slowly taken over be Physician Assistants, a program that I supported back in the early 70’s as the U.S. was coming in with theirs.
It was about that time that the Calgary medical school had, as their Dean of Medicine’ a young, bright acquaintance of mine, Dr. L. McLeod. Another young family physician and I met with him and proposed a two to three year program at the Calgary medical school for physician assistants. I had a nurse working for me at the time (Pat W), that I had taught to put on and remove casts, do minor suturing, do prenatal visits, well baby check-ups and assist my office nurse in arranging consultations, investigations, etc. Pat had a group of people in certain chronic disease areas (obesity, diabetes, etc) that she worked with regularly and councelled, and made house calls on palliative care patients. This expanded the number of patients that I was able to accommodate in my practice by approximately thirty percent and I feel, improved the care that I was able to give overall in my practice. Unfortunately, our universal healthcare system provided no means for charging for her services (I could only charge the system if I, as the attending physician, gave the service personally), so when our great leader, Mr. P. E. Trudeau, brought in wage and price controls and “extra billing” was outlawed, I had to discontinue the program because it represented an overhead that I was unable to recapture.
With this practical experience, I felt strongly that we should move in the direction of physician assistants provincially, with a billing system specifically for their services. Unfortunately, Dr. McLeod felt there would be too much conflict with the department of nursing and other jurisdictional headaches, and did not pursue establishing a school for Physician Assistants.
I found it interesting that Mr. Ferrabee quotes an annual median income of $70,000 for Physician Assistance in the States. This certainly doesn’t correlate with charges that are reported by Canadians when seen in the U.S. by physician assistants. They rarely report being charged under one hundred dollars for their visit. The median income for a Canadian family physician doing ongoing continuing care (excluding walk-in clinic docs), probably runs in the range of $100,000 to $130,000 per annum after expenses, and our office visit charge in Alberta is app. $30 a visit. Either the Physician Assistants in the U.S. are being ripped off by a huge overhead beauracracy, or our Canadian physicians are outworking the U.S. assistants by a mile.
Interesting also was the statement that in the U.S there are 62,000 jobs for PAs and only 55,000 P.A.s, pointing out again the universal shortage of healthcare providers. Insulting was the idea put forward, that the resistance to such a program would come from physician groups. If we are allowed to incorporate these care givers into our practices, walk-in clinics, and emergency departments as I did 35 years ago, and not assume the cost directly from out pockets (as I had to thirty five years ago), I see no problems. If this group is to replace the traditional family doctor, then the public should be opposed. As for the hospitals themselves (other than the emergency triage area), care in today’s hospitals is too acute to have anyone but the most highly trained giving primary care.
Naively, Mr. Ferrabee thinks governments in Canada would and should embrace this idea. He should keep in mind that increased access means increased cost, and the primary goal of our politicians in to control cost. Our waiting lists (risk lists) are our implements of sustainability.

Thursday, March 22, 2007

I Want To Donate.

Bill Murray, the Calgary chartered accountant who presently is launching a constitutional challenge to Alberta’s healthcare laws, is my hero. Is there a web site that one can donate money to his cause? Kudos also to the Calgary herald and John Carpay for the article in the Calgary Herald, March 22.
To know where justice lies on this issue, one only needs to know a few facts:
1) His orthopedic surgeon recommended this was the best procedure for him.
2) He was turned down by the Alberta Healthcare Plan based on his age.
3) The surgeon was certainly aware of his age, and, in part, recommended the procedure because of his relatively young age.
4) To carry private health insurance in Alberta is illegal.
5) The patient had to pay for and got the procedure in Montreal.
6) The Government bases their medical coverage on the availability of “relatively” scarce resources (money, so they claim).
7) All medical decisions on the government’s part are therefore suspect, not just on the basis of the lack of personal and medical knowledge of the patient, but also the fact that the government is in a conflict of interest. (Saving money in healthcare to put into education, infrastructure, etc).
8) The above scenario forces patients into the position of not being able to insure against quality of life hazardous events and life threatening events, but refuses to provid treatments recommended by a specialist physician.
9) The above scenario flies in the face of the intent of the Canada Health Act (The rich buy beneficial and necessary procedures unavailable to the majority of Canadians.
10) Constitutionally, discrimination on the bases of age is wrong. Therefore the decision as to what procedure is best is a medical one.
11) Do we want the government to dictate our medical care or do we wish this to be done by our personal physician/physicians?
What really burns my butt is that the Alberta government has the audacity to use my tax money to hire six lawyers to fight this one Albertan. Mr. Carpay states: The Alberta Government should end its legislative ban on private health insurance, rather than spending tens of thousands of our tax dollars defending against Murray’s assertion of his constitutional rights”. Amen to that; except it won’t be thousands of dollars in legal fees for six government lawyers------try MILLIONS.

Wednesday, March 21, 2007

Anger Management

I really enjoyed the movie “Anger Management”; but it was just a movie, meant to entertain and make money at the box office. In the real world, anger is complex and destructive, and from where I sit, is one of the most significant negative players in our chaotic world, both at a personal level, and at the international level.
In my early years of practice I had an eighteen year old patient that had made seven or eight attempts at suicide over the previous four years. Her attempts varied from drug overdoses to slashing her wrists. After much consultation with colleagues, she was sent to The Ponoka Mental Institution for psychiatric intervention. After six weeks of treatment she was discharged back to my care and, much to my amazement, never again attempted suicide. On one occasion approximately a year later I asked her if she ever thought of suicide. Her angry response was “I wouldn’t give him the satisfaction”!!
Now I was curious. I telephoned her psychiatrist and asked what had transpired and how he had managed to get her to discontinue her suicide attempts. He responded “Some people have so much anger and so much pathology generating that anger, that there was little or no hope of sorting it all out, so I gave her something to be angry at------me”. “And how did you do that”, I asked? “Simple”, he replied, “I simply humiliated her each time we met”.
That case has always stuck in my mind over the years. Do we all, perhaps, need someone to be angry at? It is certainly less painful to be mad at someone other than yourself or someone you love. Are we actually increasing violence by being “nice” to everyone and not giving them an opportunity to exhibit anger? An article in today’s Herald by Robbie Babins-Wagner, chief executive of the Calgary Counselling Center, speaks of violence simmering just under the surface. I’m sure she wouldn’t appreciate my spin on this, but is that because with all our political correctness, people are discouraged and prevented from expressing their daily frustrations and displeasures? Until they finally blow?
With these thoughts in mind, I turn to the world stage. Perhaps the United State’s foreign policy is responsible for 9/11. By being successful they continually humiliate the rest of us and that continuous humiliation has directed the world’s anger in their direction. Does that mean that the people in Canada who hate the United States are envious of the U.S. and deep-down, consider themselves losers?
The U.S. certainly has become a “lightning-rod” for hate in the Middle East. Was this a deliberate ploy by the clever Bush administration to prevent the people of the Middle East from killing themselves and their neighbors (as they certainly seem to want to do), by supplying them with someone to hate and direct their anger towards? It certainly would appear that in Iraq, if the various factions aren’t attacking the U.S,, they are killing each other and blowing themselves up. Recently, when Israel and Hamas (Lebanese) stopped killing each other, Hamas and the existing Lebanese government turned against each other. It would seem that we as humans need someone to hate and somewhere to direct our anger, or we become self destructive.
O.K, maybe I’ve gotten a little carried away, but one thing is obvious to me. In today’s world, it is becoming harder and harder to find an acceptable area to express our anger and frustration, and easier and easier to find someone else to blame. The United States seems to have become the world’s “whipping boy” by virtue of their success and that they “humiliate the rest of us”. Perhaps as Canadians we need to take more pride in what we are doing, or do more things of which we can be proud.

Tuesday, March 20, 2007

Observations as a Physician Patient

It is interesting what goes on in out healthcare system. My wife, presently undergoing chemotherapy, was the 17th in the lab waiting room this morning for her blood test. Before her turn came to have the blood test, approximately fourteen more patients arrived in the room that was about 12 feet by 18 feet in size. This, I know, is a common scenario in our laboratories in Calgary today.
Of interest from a medical perspective is the fact that many of these people waiting for blood tests are doing so because they are ill, many of them with infectious diseases. Of concern to me, as a medical practitioner, is that people on chemotherapy, and people with malignant disease have impaired immune systems, and are at risk for infections. Of particular concern to me this morning was the fact that my wife required her blood work because one week ago her total white blood count was 1.3 and her neutrafil count was 0.4, thus putting her in a particular high risk category.
When I was practicing family medicine I would do my general check-ups and generally see my non-infectious people in the morning, and left openings in the afternoon for the morning phone in fevers, coughs, etc. They would be shown directly into the examining room and not spend time in the waiting room. A few years ago, cancer patients with extremely low blood counts had their blood picked up at home to avoid un-necessary contact with the contagious public. I wonder if these changes have been determined by “evidence based medicine” or “cost effectiveness”.
Since the lab we attended was part of the “community regional health clinic” I found it interesting that only one person was waiting to be seen by a physician in the urgent care facility. I guess the public still prefers to see private practicing physicians. In the case of the laboratories, we have no choice.
Could it be that as choice decreases, quality of care decreases? Just a thought.

Friday, March 16, 2007

Doctors Deal Offers CPR

A cowboy friend of mine observed many years ago “opinions are like &ss h%les, every ones got one”. The editorial “Doctor Deal offers CPR” in Thursday’s Calgary Herald (March 15/07) exemplifies his position!
The editorial starts out with the position “The two-year proposed contract between the Alberta Medical Association and the province is good for doctors. It’s even better for Albertans, who have been paying the price with their health for Alberta’s Physician shortage. Well, at least they got that last part right, but it pretty well ends there. The writer goes on to give advice to the doctors “Physicians should listen to the A.M.A.’s recommendation and ratify the deal”, now here is the clincher for the doctors “because all Albertans, especially new ones, need and deserve their own family doctor.
Now, keep in mind that I am retired, so I really have no axe to grind other than as a senior, I will likely have to be more dependent on our health care system as time goes on; but my doctor friends are largely approaching my age and they keep me pretty well informed as to what’s happening---------and it’s not pretty.
Consider the following:
1) Rental rates in Calgary have jumped five to six times the 4.5% increase offered.
2) Every business window has a “Help Wanted” sign in the window. Good luck at finding good office help at a 4.5% increased wage.
3) Other office costs, taxes, etc are increasing at a rate equal to or greater than 4.5%.
4) Office expenses for a family doctor doing fairly comprehensive patient care and management run at least 45% of billings. This means that take home pay for family doctors may actually decrease during this two year period with the proposed agreement.
5) A.M.A. negotiations since 1969 (the introduction of Universal Healthcare) has kept up with inflation approximately one third of the time and is largely responsible for the steady decrease in available family physicians.
6) At present, there are areas that family physicians can work outside of the healthcare system. Botox shots, varicose vein treatments, other cosmetic treatments, specialist extenders,etc, provide better revenue for time spent than running a family practice. Even working within the system, we can do much better working as walk-in clinic docs, hospitalists, and Regional health clinic docs; and have a much better home life.
The bottom line will be that we will see a continuing erosion of the availability of family docs.
The editorial states that Alberta physicians, with this contract will be “among the highest in the country, and tied only with New Brunswick”. Good Grief!!!! What does a house cost in New Brunswick? What does it cost to run an office? Surely this editorial was the work of a high school student given a chance to be “Editor for a day”!!!
The final insult to family docs was the statement “There is no shortage of students who want to be doctors. The Medical faculty had U.of C.’s highest entrance grade last fall, at an average of 89.1%. Everyone else was turned away, even those with slightly lower grades who might make wonderful family doctors”. What the!!!!???? Are they saying that you don’t have to be as intelligent to be a family doctor?? The editorial then goes on to say “As long as admission is restricted to the intellectual elite, provinces such as Alberta will have trouble attracting and retaining family physicians”. I think the writer really does think that family physicians are not the intellectual elite and that specialists are!!!!
Here is a news flash, Mr/Ms editor.The last time I looked at the breakdown of medical students, family doctors came primarily from the middle one third of the class and specialist came primarily from the lower third and upper third of the medical class. Specialists coming from the upper one third were more likely to go into research areas. Focusing on one aspect of medicine is often viewed as being easier than being a generalist, which requires a good knowledge of a wide spectrum of medical fields. Specialists spend four to five years of additional training in their specific area, and they certainly should be the authority in that area; but it does not mean that they are more intelligent. In any case, the statements were dumb and demeaning, and certainly won’t entice talented medical students into choosing family medicine.
For those who may be interested, here are some of the real determinants used by medical students when choosing their area of medicine: (not necessarily in order of priority).
1) Primary area of interest.
2) Years of training required
3) Cost/ability, to continue studies
4) Remuneration in practice
5) Marital status
6) Family status (children)
7) Availability of residency training
8) On call status during training and after graduation.
9) Expectation of home-life and personal time after graduation
10) And finally, in some cases the “milk of human kindness” aspect.
11) If some docs are reading this, you can add more, but ability is NOT the issue!
So there you have it, doctors of Alberta. This brilliant editorial suggests you ratify this proposed agreement. If I were a voting member of the A.M.A., my vote would be an unequivocal NO! ---------for the good of all Albertans, and the right of every Albertan to have a family physician.