Several recent experiences with patients in my family practice have given me cause to think deeply about the nature and challenges currently existing in Canadian medicine. I have been privileged to work for 16 years in rural practice followed by 20 years as a practicing academic physician with health education and systems experience on three continents. For many years I have worked with American colleagues and have had experience of working in America. Thus I have some 40 years of practice on which to reflect when helping patients navigate a complex health care environment. One advantage of my widespread geographical, social and temporal experience is the perspective it gives to my current work.

By and large, that perspective has been one of gratitude. Gratitude that I have been able to see some of my current patients for over 35 years. Gratitude that during most of those years I have been able to offer timely access to the best available consultants, investigations and treatment without worrying about potential devastating impacts on their family finances. Gratitude for collegial support and the presence of students to ensure a constant push to be the best doctor I can be. And, very importantly, gratitude that as we look objectively at the data on equity, cost-effectiveness, quality and relevance of the care that is so much fun to give; the Canadian system stacks up very well compared to the many alternatives on which we have data. An enjoyable practice, supported by evidence of benefit to patients of a public system is a pretty fortunate thing to experience.

This blog begins with a personal narrative simply because it is narrative that builds political discourse and social change—evidence is, sadly, secondary. However, it is important to ensure that the evidence supports the narrative if we are not to live in a world of political delusions and foolish actions.
Thomas Jefferson once said of democracy that its cost is eternal vigilance. The same is true of effective and equitable health care systems. In this regard, Canadians are letting each other down - and we are all part of this. Despite being wealthier than ever, Canadians have not only been allowing their system to drift but are starting to question its “sustainability”. This means that we are questioning our commitment to one another and no ideological diatribes about affordability should distract us from that fact. We are all familiar with the arguments about rising proportions of expenditures, tax equity, proportion of GDP, reduced public spending on infrastructure and the general decline towards meanness in our political discourse and public commitment to the common good. Depending on one’s political perspective the various data can be parsed and emphasized in a variety of ways—including the current attempt to spread panic and jump hastily into increased privatization of access to care.

We must keep in mind that such attempts would find little purchase if our system was functioning up to its real capacity. Across the country Canadian doctors, professional colleagues, institutions and, yes, even politicians have demonstrated their remarkable capacity to respond positively within the public system to simultaneously increase access, decrease costs and maintain (or even enhance) quality of service and outcomes. A continued and concerted drive in that direction clearly warrants more effort than foolish moves towards commercially based care whereby access to care is based on ability to pay rather than evidence of need. Such a commitment will be rewarding to all Canadians. Outreach initiatives, like the following examples, can benefit all Canadians:

-The Assertive Community Treatment initiative that reduces hospitalizations, saves money, and improves the lifestyles for clients with severe mental illnesses;

-The New Health Professionals Network’s (NHPN) Tommy Douglas Prize Winners;

-Family health teams and associated improvements in quality and efficiency of health care services and delivery;

-Ophthalmological collaborative care initiatives in Nova Scotia;

-Cardiac care initiatives in Ontario; and

-Federal Ministry of Health sponsored expert review of fertility treatment which concluded that bringing treatments into public system would improve quality and oversight.

But there is an as yet untapped source for savings and quality in our system—and one that we as physicians have a particular responsibility to promote: we let our patients down upon their first contact with the system when urgent care is needed. We let them down as primary care physicians by being inconsistent and even inconstant in ensuring that they can access someone who knows them, or someone who knows their primary caregiver. We let them down in our emergency rooms by over-investigating them to great expense, causing considerable anxiety and little or no good effect.

This brings me to a recent patient who - while I was out of town - took himself to the emergency room for some heartburn-like chest pain because the media had re-enforced that if you have chest pain you should go straight to the emergency department. A distressingly common and predictable cascade occurred. The exuberant investigations showed a slight elevation of a blood clotting test, the subsequent CT scan of the chest showed an ambiguous tumour on the kidneys, the referral led to ominous statements about kidney cancer and surgery. The highly discomfited patient came to see me on my return while awaiting a specialized kidney CT scan the next day. This simply confirmed a known set of benign kidney cysts that no-one had asked the patient or his physician about. The instigating symptom of chest pain had disappeared with a simple course of antacids. This cascade of thousands of dollars and some intense anxiety took place over less than a week so access to investigation was not an issue. It was even perhaps the opposite! This is not to fault any professional behaviour within this series of events. It is to say that, had we designed our system with relationships in mind rather than disease-states, we would not need the elaborate and frequent over-investigation and treatment of such ambiguous incidental findings routinely brought forth by “advances” in investigations and imaging. This patient could have been treated, well within the boundaries of evidence based medicine, with a few dollars worth of antacid and observation by someone who knew him. Not only would this contribute to the sustainability of the system but would have freed up imaging time for more appropriate shortening of the wait times that cause anxiety to so many and self-serving arguments for some.

Canadian Doctors for Medicare is committed to the use of evidence in addressing improvements to Canada’s health care system so let us move beyond this narrative to potent evidence. Very powerful evidence of the practical application of this perspective can be found in the experience of the Alaska Native Medical Center. This is a 45,000 patient clinic primarily serving Native American patients through 375, 000 patient visits per year. It was described by director Davis Eby as initially being “a big, impersonal, ‘crank-em-through’ type place” . The clinic undertook a process of change from a “staff centred” to a “patient centred” model, and for the past three years, patients have been guaranteed their own primary care provider. This patient-provider match is achieved for 75-80% of patients, moving them beyond relationships characterized by multiple caregivers to having reliable contact with a single point of care with subsequent connections to needed services beyond. In fact, they DID NOT undertake the usual initiatives associated with the P.H.C. reform such as:

-Nurse advice lines, separate health coaches;
-Triage in primary care;
-Different appointment types;
-Disease specific primary care teams for diabetes, asthma, etc.; and
-Performance incentives that often have perverse, unmerited consequences.

What they DID achieve is quite remarkable:

-Use of the Urgent Care Center for primary care is down by 50%;
-Use of specialists is down by 30%; and
-Wait times have decreased significantly across the system

This impact has not been achieved by any of the far more elaborate and more expensive innovations carried out in the rest of North America. In reflecting on these results, Douglas Eby makes some very trenchant observations:

“We want to tell the world: It’s not about access. Access is only a tool that helps create relationships because it breaks down barriers. Relationships are really what it’s all about…It is only through solid relationships, that you can begin to get at insidious underlying health issues such as depression, domestic violence, and obesity.”

So, yes, let us look at systems change within a framework of quality, equity, relevance and cost effectiveness. Let us at the same time be mindful not to succumb to a sense of beleaguerment that blinds us to the fact that daily vigilance to the things we can change is required of each of us. Our patients deserve no less.

1. http://www.ihi.org/IHI/Topics/PatientCenteredCare/PatientCenteredCareGeneral/ImprovementStories/Building+Healthy+Relationships+at+Alaska+Native+Medical+Center.htm