Dr. Merrilee Fullerton on Healthcare

A physician who holds a fairly significant position in an academic teaching centre recently commented in the Ottawa Citizen, August 26, that he feels that primary care needs to be better organized.  One  solution he proposes is to explore primary care pilots that include paying physicians significant sums for administrative work.

He also thinks it would be a good idea to have family doctors fall under the purview of the Local Health Integration Networks so that family doctors would be given the infrastructure to meet regularly and discuss how to address patients who don't have family doctors.

His premise included the concept that  existing physicians could somehow arrange to divide the existing orphan patient population. He is reported to have said:

"..if we each take however many, we solve the problem."

Although this physicians' ideas are noble in intent, it is important to realize that government is not the only way to be organized and that there are existing structures already that allow for communication and organization amongst physicians. These include existing groups of doctors working in real life clinics as well as virtual groups of doctors who may practice separately but who communicate regularly and who must organized themselves to provide care for their patients without being told by government bureaucrats how or when to do their jobs.

Trouble is that some physicians are not particularly interested in being involved in meetings outside their day to day duties. Whether this is apathy or self-preservation is up for discussion. But the idea that we need more administration comes at a strange time when productivity of physicians in new models is being questioned. The argument goes that other countries are doing better than Canada in organized primary care but the reality is that to be brought up to OECD standards for physicians per capita, we would need 26,000 more physicians in Canada today. Hate to tell you this but it ain't going to happen anytime soon.

However, as we move to new models of primary care, often driven by policy and not evidence, it becomes increasingly clear that the government agenda is to budget and control.The likelihood of adding more administrative funds instead of patient care funding is not very realistic when we seem to have a black hole for health care dollars that don't necessarily get to patient care.

We are already lacking the physician resources and even nursing numbers to cover the coming needs. Losing more doctors to administrative work hardly seems reasonable to me let alone spending more on administration when the loads of paper work (real or virtual) threaten to crush us mentally and even take a physical toll.

What does this have to do with the OECD lowering forecasts for the Canadian economy, you ask?

Well, if the outlook for growth for Canada's economy is as dire as predicted by the OECD..less than one per cent and less than half of that of the US economy.....the 0.8% growth just isn't going to allow for much more health care spending, at least I hope not on more "administration".

While some doctors like the one mentioned seem to believe that more administration is the answer, others like the new CMA president, Dr. Robert Ouellet, don't agree. His comments in the Toronto Star September 3 indicate that he believes   movement away from spending on increasing administration is needed and that the role of private care alongside a universal system is quite complementary. Bravo.

At least someone can look past the mountains of administration and see the patient. There is hope.

Please feel free to comment as always and even to continue the previous comments from the other journal entry. I don't want to cut anybody off!

Okay, so I did let the last string go on too long but as someone eluded to, we always seem to come back to the same themes. I expect this short discussion on the whole Insite program will lead to the same issues which are funding, funding and more funding.

I've been following along on the comments from various papers including the Toronto Star and Globe and Mail and I'm not surprised to see the usual indignation from doctors and others along the lines of the "proof is in the proof".

Now don't get me wrong, I fully support the concept of harm reduction if it really can help those addicted. The problem I see is with the tunnel vision approach that improving HIV spread should somehow be the raison d'etre of the Insite program. Some will argue that the availability of the safe injection site makes accessing detox that much more likely. Fine. Offer the Onsite detox program as well but why the wait and why the inadequate resources for treatment programs?

If you really wanted to control the spread of disease and destruction from drug addiction, wouldn't you want to have an accessible and adequately funded treatment program? Such is not the case with access to treatment programs lagging seriously while "harm reduction" strategies are funded instead. 

It seems to me that "harm" defined as the transmission of HIV is a bit lopsided since harm related to drug addiction comes in many forms. More treatment programs and addiction services are needed while the debate over "harm" goes on.

Above and beyond the whole safe injection site debate is the strange optic of doctors being indignant over Mr. Clement's questioning of their actions in supporting drug use. Since when were doctors' decisions and opinions 100% pure and always accurate? Is it not reasonable to question our actions from time and time and revisit how we provide care, how we manage care and what is funded?

Why is it that we doctors take offense at the questioning of a fairly controversial program? Haven't we seen time and time again in the history of medicine that the care we provide requires revision and reassessment from time to time?

The idea that anybody, including doctors, would be embarrassed by  a reasonable question as asked by Mr. Clement is beyond me. But I'm not embarrassed by their embarrassment since I realize that it is all political posturing. To think that a CMA ethics committee member would get up and chastise Mr. Clement for making a quasi political speech on Insite ethics is rather ridiculous since CMA General Council itself with media present is one way of mixing medicine with politics. To think that the CMA is somehow purely medical and not political in nature is truly blind... Otherwise, close the doors to the media.

I wonder who the real puritans are.

Please feel free to add your comments on the Insite program or any of the usual recurring themes.

Kind regards to all of you who continue to contribute and to those who read along. Enjoy our last days of summer!

We've heard rumblings from various parts of Canada regarding physicians or groups of physicians holding lotteries for access to their care due to shortages of medical providers in many parts of the country.

The National Post reports August 6th that a Northern Ontario physician, Dr. Ken Runciman, reluctantly eliminated about 100 patients in two separate draws to avoid having to provide assembly line service or extend onerous work hours.

In Newfoundland, a lottery was held last month to allow a new family practice to  "pick  its caseload from among thousands of applicants".

The National Post also reported that  "an Edmonton doctor selected names randomly earlier this year to pare 500 people from his heavy caseload".

Jill Hefley, spokeswoman for the College of Physicians and Surgeons of Ontario has said there are "all kinds of ways that doctors are trying to deal with their patient loads" and that the CPSO is not against lotteries and other random systems for cutting back.

And so while some doctors are accused of  avarice for seeing many patients using a fee-for-service funding model, I am hard pressed to understand how, with a shortage of providers of all kinds, we going to manage to service all patients requesting or requiring care.

Providing "holistic care"  as Dr. Runciman prefers, spending 15-20 minutes per patient, should be appreciated but what happens to the patients who are let go? Is it better to have the patients retained in his practice having this kind of "holistic care" and  others who are "lotteried out" of the practice with potentially  none  or is it better to have patients put through more quickly, all of them  seen and the doctor to sort out who needs more investigation or referral?

As a physician, I happen to prefer the 15-20 minutes per patient approach, simply because it is less stressful for me as a provider and because most patients are satisfied with this time. However,  if all physicians approached care in this way, I expect that the physician shortage would be even worse. Coupled with a nursing shortage and human resource shortages of many kinds, it is folly in my opinion to think that the "holistic" team approach, although much ballyhooed, is really the solution to sustainability in primary care.

The patients who can access it may be very satisfied...and the physicians who choose to practice this way may also be satisfied, but it doesn't address the looming larger issue which is the lack of access for the others and the cost of this kind of approach if physicians, particularly in team models, see fewer patients and work fewer hours and more layers of providers are required.

Recently the Health Council of Canada published its report,   "Sustainability in Public Health Care: What does it mean?" , and also suggests that it is team-based care that in part will provide sustainability for public health care:

"..providers can be organized into teams to manage care more effectively.....The next step may be to convince medical professionals of its soundness. Given medical school's more comprehensive and integrated learning curriculum, interested champions can make this happen."

Yet, in the same report, the Health Council appears to admit that choices will need to me made regarding "wants" and "needs":

"Canada's health care system does not have adequate means of separating wants and needs. Decisions must be made about choices and limits. While limits are implicitly set in some areas already (some services are not publicly funded), an explicit ethical framework may be helpful in resolving some debates. When tough choices need to be made, both decision-makers and the public must be confident that they are made fairly".

Is a lottery for access to primary care "fair"?
What does it tell us about our system's ability to provider "universal" care?
What does a lottery tell us about our system's "sustainability"?

It would appear to me that the experts have lost sight of what is  happening in the front lines of health care and while teams are fine and well, they will not be the solution to primary care sustainability and certainly not productivity issues within health care.

But some don't care  just as long as they produce more reports.

I'll post the links in the comments section.

Best to all of you,

Realist

First, I'd like to thank all of the contributors on this blog for their most informative and insightful comments. I am continually in awe of the knowledge and experience that exists 'out there' which makes me wonder why it is that we can't seem to manage to circumvent "the political stick in the spokes" of health care.

In this recent CMAJ article from July1, 2008, "Public engagement in setting priorities in health care", which I will hopefully be able to provide the link for in the comments section, it is clear to me that a significant degree of innocence  exists in some academics' minds. The University of Toronto Priority Setting in Health Care Research Group (how's that for a long acronym: UTPSHCRG!) reports on the value of public engagement, perceived barriers, ways to increase public engagement and cautions and realities.

Although the researchers do admit, " It is important that the requests for public input not be overtaken by advocacy groups. In our current system, there is already ample opportunity for disease-oriented groups to engage in political lobbying and, although their voices should be heard in public-engagement exercises, it is the "unaffiliated public" who have the least say in decision-making, with important societal implications."

Now folks, you've heard all of this before, right here on this blog on numerous occasions and I did not receive a research grant or command a salary...or even receive a golf membership for my efforts. I certainly agree with the researchers' understanding of the importance of this. The funny part, or not-so-funny part depending on how you look at this, is that they seem to think that the public can engage in priority setting without this happening.

"All deliberations made with public input need not be conducted in public. There can be great value in an appropriately constituted decision-making body meeting in private, but then publicly disclosing the results of deliberations. This is analogous to the private deliberations of juries in our legal system, which allow them the opportunity to discuss freely, question and argue to arriveat the best decision."

Yikes.

It would seem that this research group is entirely missing the point  that the person caught up in a legal problem has the opportunity to pay for their own lawyer should they wish to.They are not required to accept  a court appointed lawyer. Sure, ultimately the lawyer will plead their case to the jury if there is one, but to think that public priorities can somehow be set behind closed doors without some political intervention is a very innocent perspective. This will improve trust and "confidence in the health care system"?

The idea that the Canadian public can determine the priorities for all of us without taking into consideration the unique needs of individuals which may or may not be met in a publicly driven system is tantamount to ignoring the needs of minorities.

I'm not against public involvement in health care priority setting, but I've been around long enough to know that politics will always be part of publicly funded priorities---make no mistake about this .

 

 

 

 

The conversation on the previous journal entry including C. difficile outbreaks in hospitals across Ontario is worth continuing so please feel free to post comments that may be relevant.

However, I think it is also time to discuss the damage that top down control is creating on members of the public service including nurses and doctors as shown in a recent study from the Association of Professional Executives of the Public Service, APEX.

In an article June 16, 2008 from the Ottawa Citizen, "Public sector ' a toxic place to work' ", a national inquiry into the management and working conditions of the public sector is called for.

Bill Wilkerson, chairman of the Global Business and Economic Roundtable on Addiction and Mental Health is reported to have said that absenteeism, disability and claims and distress among Canada's nurses, doctors, teachers, police, military and bureaucrats have reached a crisis proportion and it is time for a major study into what is "sabotaging taxpayers' investment" into these critical services.

What is it that is creating such high levels of distress?

What is wrong with the culture of the public workplace?

Disability claims in Canada are climbing and currently 30-40% of claims are for depression. Cost to the economy: 51 billion (4% of GDP).

The APEX study showed that 64% of executives think of leaving their organization at least every month. More than half want to leave because of lack of recognition.

It is the first study to show the toll of technology and how the reliance on technology has become "counter productive".  About 75% of the nearly 2,100 surveyed say technology increases their workload; 66% said it adds to their stress and 49% said it decreases their productivity.

"People are drowning in technology and risk averseness and the lack of clear lines of accountability" says Wilkerson and "senior bureaucrats could feel "policitized"-torn between being neutral, non-partisan professionals being drawn into the political arena".

The last paragraph provides the most clarity:

"Part of the problem in the public sector is the ambiguity around who is in charge. Departments have to manage with a slew of "one-size-fits-all policies" and answer central agencies from Treasury Board to Privy Council Office. As a result, departments don't feel like they are employers in their own right," says Mr. Wilkerson. "

This certainly applies to productivity issues in the medical world. When top down approaches constrain  highly trained and responsible  professionals and create an inability for them to  function to their full capacity we have reached a significant tipping point.

Mr. Wilkerson and senator Michael Kirby plan to convene a workplace summit this fall into the productivity and health of the public sector, "especially the hardest hit health care sector".

Let us hope that the solution is not more rules and regulations and stifling of innovation, entrepreneurship and independent decision-making....but I'm not holding my breath.