Until last summer, I was associate professor of medicine and a practicing physician, who is passionate about social justice in this country. I feel strongly that our Medicare system should be strengthened instead of eroded and dismantled.
This issue has come to attention yet again because of the dispute between the Ontario physicians and the provincial minister of health, Deb Matthews, who according to Pauline Tam of the Ottawa Citizen, is threatening to impose a pay freeze, given Ontario's $15-billion deficit.
We should never allow the privatization by stealth of our health care system, and we should make certain that the Canadian taxpayer never foots the bill of a "Two-Tier System." We should be constantly improving our existing single payer national health system to keep up with the ever increasing demand of the ageing population estimated to double within 20 years, and with exploding new technologies, in genetics, imaging and neuroscience, to name just a few.
There is a serious shortage of primary care physicians in the whole country, and it is very difficult if not impossible to find a family physician these days. In the past few years I myself had to see patients who did not, and could not find a primary care physician to follow up on the treatment and advice I gave them.
You would think that the leaders in medicine from both sides would strike a joint committee and solve the problem, but it does not seem to have happened, otherwise the problem would not be front page, yet again. Very briefly, here is a proposed nation wide plan:
A: We have a nationwide shortage of 26,000 family doctors, not to mention para-medical staff. On the other hand, there are 7,000 foreign trained physicians, who need to be fast tracked, after ensuring their competence. Licensure requirements should be identical in all provinces. It would make accreditation streamlined, allow immigrant physicians to settle in the province of choice, and would make the annual licensure fee I pay as a doctor cheaper by reducing the overhead of the 10 or so different licensing bodies. There is no excuse at all for having different standards of competence in medical practice, in Saskatchewan and Ontario. The life of a Canadian in Saskatchewan cannot be cheaper than one in Ontario. It is all about power and about groups of people guarding their own turf. Intake into medical schools needs a significant boost. We need to make up for the misguided policies of the past, when medical school intake was reduced, and for which we are paying today.
B: While these medical students and foreign medical graduates are being prepared, retired physicians, like me, may be persuaded to do part time tel-medicine or e-mail consultations, as long as they have medico-legal protection. A retired physician may not brave the winter weather to report to a hospital or office any more. But she could give an opinion from the comfort of her desk using e-mail or Skype or other format.
C: Doctors spend up to 30% of their time on paper work. Most of this could be done by non-physicians, at a fraction of the fee. The electronic medical record (EMR), a fact of life for all Taiwanese today, should help greatly. Any minor problems of confidentiality should be ironed out. Doctors do not need to measure blood pressure or syringe waxy ears themselves. Nurses can do a much better job. Delegate! Delegate! But delegation can be used further down the line too. In the sleep laboratory, where I was director, I learnt to my horror that appointments were given on the phone by the sleep technologists who actually record sleep at night, and who are board certified in that very technical field and who are paid around $25 per hour. Would it not make sense to have an ordinary receptionist do that at less than half that hourly rate?
D: Family physicians (F.P.) see so much anxiety, depression and insomnia, the discussion of which takes many minutes. At my own family physician's practice, a regular visit is allotted only 15 minutes; the annual check-up, 20-25 minutes, while counseling takes 45 minutes. We need to train more psychiatric social workers and physician assistants, and nurse practitioners. This system is already working well within the Canadian armed forces, where I was consultant for years. It takes seven years to produce a family doctor, 10-11 a specialist, and four for a nurse. A survey in the U.S. estimated that 17% of war veterans exhibit post-traumatic stress disorder (PTSD). The Canadian figure cannot be too different, as I noted when I worked as a consultant at the National Defense Medical Center over the past 18 years. Why are we in combat role in this war in the first place? And why are we spending over $20 billion a year on war, when we claim that we cannot afford to upgrade our health service? Priorities! Priorities!
E: Patients often expect and even pressure their F.P.s to order investigations. But the Canadian Association of Radiologists estimated that only 84% of radiology referrals were appropriate. The cost of the inappropriate referrals is half a billion dollars! Imagine what can be done with that money every year. We need to do something about this. Family doctors need to be consulted about this, not just the radiologists, or some bureaucrat at the Ministry of Health.
F: The cost of drugs can be astronomical. And yet there are ways of reducing the total drug bill by buying generic, and varying the source of purchase, including buying from foreign countries which produce cheap but safe and reliable drugs; and by bulk negotiating with drug companies, for all our provinces; another reason why health standards should be the same for all provinces. This strategy has already been partially adopted.
G: Physicians are well paid for the work that they do, compared with other university graduates with the same intelligence and even similar working hours. Minister Matthews pointed out their average annual income of $385,000, with many making twice that figure. Over the past nine years their income has increased by 40%, which the minimum wage has not! Quite rightly, she said, "If I spend it on paying doctors more, increasing their income when they are already the highest paid, that's a dollar I cannot spend on home care." But their working conditions could certainly be improved and their stresses thus diminished, to lessen their burn out. Their working hours are long and they are constantly expected to think on their feet. When they leave the office, often late for their dinner at home, they still take some of their work home.
H: There are major differences between the incomes of different specialists, whose training is almost identical. That makes absolutely no sense, and it contributes to jealousies and frustrations, because some fees assigned to certain specialties, are astronomical and highly inflated. It depends on whether that specialty has a money-generating "gimmick." The time spent performing EMG is well rewarded at hundreds of dollars per hour, and yet the same neurologist performing a potentially dangerous lumbar puncture gets only $50, the last time I checked. A sleep specialist, like me, interpreting sleep tests would make $1,280 per hour. No, it is not a typo! How can a psychiatrist, also with a fellowship of the same Royal College of Physicians, be happy about that when she/he would make $150? How can that be, you may ask? It comes from pre-computer days when interpreting the data collected over eight hours of sleep did take an hour to analyze. Now, it is all computer-generated, and it took me an average of six minutes to analyze and dictate a full report when I was working last year. Don't expect these specialists to demand that you reduce their fee. What should happen, of course, is to put doctors on salary, a very good one, which rewards their long training and arduous daytime work and horrendous night call. That way, sleep specialists with the cushiest job, cardiologist, nephrologists, and neurosurgeons will have equal pay, and stop vying with each other for more money and appreciation, on the pretext that their specialty is harder than all others, or that they are somehow more clever or more deserving.
I: Go Green! How about a big and sincere campaign for prevention of disease, by living healthy lives, including the elimination of air and water pollution and radiation, adopting a healthy diet, buying local, promoting exercise by providing more bicycle paths, spacious parks, and by eliminating sales taxes on sports equipment? Think of how weight loss alone could reduce the morbidity of diabetes, hypertension, heart disease and sleep apnea, to name just a few.
I hope the ministry of health is paying attention, but I am not holding my breath.
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