Apparently we have a Doctor crisis. Certainly that’s the impression one would gain from articles, columns and letters commenting on the recent impasse between the government and doctors of Ontario. It’s also the impression that many medical students have been left with after the decisive defeat this summer of the draft Physician Service Agreement developed and endorsed by the Ministry of Health and Ontario Medical Association.
The OMA not only represents all Ontario physicians, but also includes in its voting membership all students enrolled at Ontario’s six medical schools. Those students, who were very much involved and rigorously lobbied by both sides in this debate, have now returned to their studies considerably more uncertain about how physicians and government interact, about how physicians function within the health delivery system, and about their personal futures as physicians in this province. I think it’s also fair to say they’re a little dismayed by the tactics and rhetoric on display through the lead up to the vote. Simply put, they seem a little shell-shocked about what they’ve seen and heard. They’re asking “what happened?”
In medical school, we try to teach students to always look beyond the surface and to identify root causes in understanding any patient illness and developing treatment decisions. A cough, we teach, can be easily suppressed, but failure to consider sinister underlying causes such as obstructive masses can be a disservice to the affected patient.
It’s certainly easy and perhaps tempting to characterize the dispute as a labour issue about fair compensation for service provided. However, the roots of this dispute are much deeper and it’s becoming clear that failure to understand and engage those underlying issues will both compromise resolution and render any settlement incomplete and therefore only a transient respite. With that in mind, I offer a few considerations:
Issue 1: The Blank Cheque
As Canadian citizens, we have high expectations with respect to the provision of health care. We (and let’s remember that doctors are consumers of health care as well as providers) have come to expect health care that is comprehensive and available whenever, wherever we require it. In fact, such an expectation has become an unassailable right of citizenship, as deeply rooted in the Canadian persona as hockey and maple syrup.
It’s been in place in various forms for several decades, but came to full fruition with the passing of the Canada Health Act in 1984, which states in its preamble the primary objective: “to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.”
And who can, or would, argue with the “rightness” of universal health care? We take care of our people, from birth to grave. We share resources for the benefit of all. We will permit no one to suffer for want of personal resources. Truly, these are worthy and appropriate goals of any “just society”.
However, by codifying these principles, our governments have issued what is basically a blank cheque, without limits in time or scope. The challenge, of course, is that much has changed with respect to what is encompassed by the concept of “universal” health care, and the draw on that blank cheque is growing beyond available resources. Not only is the population getting larger and older, but highly-effective (and highly resource intensive) therapies have emerged and are continuing to emerge for the treatment of conditions that previously had no options other than palliation. To name a couple from the field of cardiology, transcutaneous approaches to critical valve conditions have opened therapeutic options for patients who would otherwise be too ill or weak to tolerate standard surgical approaches. Implantable defibrillators reduce risk of catastrophic cardiac arrhythmias in patients with severely damaged hearts. These approaches are well tested and effective, improving quality and length of life in certain patients. However, they come at considerable cost, both in terms of hospital resources, training of personnel, and the devices themselves, which can run tens of thousands of dollars each.
In addition, the pharmaceutical industry has developed a variety of medicinal treatments for chronic debilitating conditions such as arthritis and chronic inflammatory conditions, powerful antibiotics for drug resistant organisms, and chemotherapeutic agents effective for otherwise terminal cancers.
As a result of all this, the commitment so nobly envisioned by our political leaders several decades ago to provide basic health coverage to all, has grown beyond what anyone could have imagined at that time. The “blank cheque” has become due, and our elected officials struggle to honour the commitment of their predecessors.
Issue 2: The Mandate of our Elected Governments.
Governments struggle to maintain the promise of universal care while attending to their other societal obligations (education, infrastructure, security, to name a few), and all while under pressure to maintain financial solvency and a vigorous economy. In fact, our governments are elected and maintained in office substantially on their ability to deliver on the universal health care promise. One can only admire the dedication of individuals willing to take on such positions of public responsibility and scrutiny. They certainly devote considerable resources to health care. In fact, Canadian governments collectively spend more on health care than most other western countries.
To make matters worse, the system is crying out for even more investment. Hospitals, their single greatest expense item, have already been cut to the bone and are now over-extended with much evidence of strain, and rightfully petition for expanded support. Home care services, so valuable to both patients in need and to hospitals in need of acute care beds, are inadequate to the demand and require drastic expansion. There is a growing pressure on government to support pharmaceuticals for all citizens, a position recently championed by the Canadian Medical Association.
There are limited, acceptable sources of new funding. There have been scattered attempts to limit their scope of responsibility to “medically necessary” therapies, but consider the public response when new, expensive but untested therapies emerge and provide hope for previously untreatable conditions, or when an Ontario citizen must seek out therapy out of province or at great personal expense. Surcharges for services were abandoned many years ago, and it’s difficult to imagine a government surviving any attempt to re-introduce them. There may well be opportunities for savings within the administration of the system and provision of redundant services that could and should be explored, but that potential certainly hasn’t been clarified, at least publicly through the current debate.
In the midst of all these demands and their “blank cheque” mandate, government turns to physician payments for financial relief. These payments, in Ontario, apparently constitute about 20% of health care expenditures (second after hospitals) and seem to provide a politically acceptable target. The unavoidable, and very unfortunate, implication in this approach is that physicians are, at least in part, a cause of the financial problem.
Issue 3: The Doctors
Much has changed about doctors since the concept of universal health care was introduced so many years ago. In the past, doctors were a much more homogeneous group. A doctor’s job and role within the community, was to care for a group of patients who engaged them. They provided continuing, comprehensive and lifelong care to those patients. They were also independent business people who were paid by their patients for the services they provided. With the advent of socialized medicine, the payment shifted from the patient to a third party (i.e. government), but doctors remained responsible for their own expenses and income, and payment continued to be on the basis of services provided. In Ontario, Bill 94, passed in 1986 despite much opposition, effectively eliminated any physician billing outside the accepted list of publicly funded services. That fee schedule, initially consisting of direct patient encounters and assessments, has been drastically expanded over the years as new diagnostic and therapeutic procedures have been introduced. Those components, usually limited to highly- specialized groups, have become the most lucrative fees and greatest overall expenses. The fee schedule now very much favours specialized procedural work over direct or continuing patient contact.
The flaws of the fee schedule are well described and have been acknowledged by all parties. It favours and promotes brief, procedurally based approaches to both diagnostics and therapeutics, and is internally divisive. Moreover, it effectively re-defines the role and expectations of practicing physicians, shifting the emphasis from continuing, comprehensive care, to sporadic, as-required interventions. All acknowledge it needs massive revision. Most recognize that nibbling at the edges by reducing specific fees is neither fair nor adequate, but even those “nibbles” evoke highly defensive responses, which surely mute willingness to engage more comprehensive approaches.
Following the expanding knowledge and growing need for specialized technical expertise, the medical profession itself has changed dramatically over the past several decades. Doctors have become highly specialized and many specialties, such as Cardiology have further divided into sub-specialties and even sub-sub-specialties. The training system is such that more technical specialization requires greater length of time, so doctors emerge from their training and engage practice often with considerable personal debt, and much older than other members of society beginning their careers.
The heterogeneity relates not only to specialty, but also practice type. Increasing numbers of physicians are moving away from the private, business/practice model and opting to work in health care groups or capitation (alternative funding) arrangements, which means that the results of PSA negotiations may have very different impacts on them. All this begs a very large and contentious question. Can a single negotiating organization continue to effectively represent the interests of so many disparate physicians? The emergence of so many splinter organizations in recent years, and the development of a coalition specifically to challenge the PSA at least challenges that notion.
Whatever their specialty or area of activity, doctors work long and irregular hours at considerable personal sacrifice, and have jobs that carry considerable levels of personal responsibility and public scrutiny. Although it would be naïve to imagine that the system is completely free of misconduct or abuse, the vast majority of doctors wish to apply the skills they’ve acquired at much effort and personal sacrifice to the service of patients who can benefit, are supportive of the principles of universal care noted above, and are content to work within the parameters of an established, fair compensation system. They would like that system to provide them reasonable compensation. They would like to be truly involved in its development. They would like to be acknowledged as part of the solution rather than the cause of the problems.
Summarizing: The Real Issues and Tough Questions.
My own view is that the reason so many physicians voted “no” in the recent ratification vote has less to do with the dollars involved, and much more with frustration over the inadequacy of the approach exhibited by both sides to the profound issues at stake. Accepting the proposed compromise without a commitment to real reform and a real role in that reform is facile and simply postpones the hard work we all know is required.
Squabbling over whether the global physician payment envelope should increase or decrease by a few percentage points will not address the real issues, and will only reset the clock until the next inevitable confrontation. Government and physicians must work together to discuss and seriously engage the underlying key issues, and the public must be actively involved in those conversations.
The issues are profound and fundamental to our national identity. What is the current day meaning of ”to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers”? It seems clear that fulfilling that commitment in our current funding model is not sustainable. Certainly efficiencies should be pursued and wastage eliminated, but the underlying commitment, the funding model, or possibly both, must change. Our choice is not whether they will change, our choice is how that change will occur.
Having our government, charged with public trust to ensure delivery of health care, at loggerheads with our doctors, so critical to the provision of that care, is both perverse and destructive. The relationship needs to improve, and the dialogue needs to elevate above superficial issues of compensation. To do so, both government and doctors must submit to an element of risk. In engaging the difficult but core issues, government risks public disapproval. Doctors risk their income and security. In essence, both parties must put something “on the line” if effective discussion is to be engaged. If both are truly focused primarily on the welfare of our patients and citizens, these should be risks both parties are willing to undertake.
We have a crisis, to be sure, but it’s not a doctor crisis – it’s a system crisis, and any solution that fails to recognize and engage all its dimensions will only provide a stop gap measure, deferring to the next “crisis”. As all patients and doctors are well aware, effective therapies often require short-term pain for long-term benefit. At some point, that pain must be engaged. If not now, then when?
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
To explore issues related to the recent physician/government impasses, the Aesculapian Society and Undergraduate Medical Program are jointly sponsoring a symposium on September 20th at 6:00 pm in the School of Medicine Building. A panel of speakers with various perspectives on this issue will be providing their insights, followed by a Question and Answer session. All students are invited to attend.