Facing the true cost of medicine

Issue: BCMJ, vol. 42, No. 5, June 2000, Pages 247-248 Editorials

When the BC Medical Journal approached me for my thoughts on where medicine is going as we enter the new millennium, I considered many different angles on the question. Then I realized that as a physician, I have been part of the Canadian medicare system from its inception.

As a member of the BCMA since 1973, an active member of the SSPS since 1991, and now as the president of the SSPS, I might be expected to wax eloquent on the current state of affairs, and where I think we are going.

I think, however, we need to first look at how medical care has evolved over the past 40 years. Medicare was introduced by a generation born during the Dirty Thirties and the Second World War.

These people, our parents, recognized that medical care must be available to all. Because many of them had been denied adequate care themselves, they would not allow their children to suffer in the same way. Thus was born the concept of universality.

However, the system has become an albatross around the neck of every provincial and federal government. It threatens to destroy everything if some drastic measures are not taken now.

There are many reasons we have reached this point, but the underlying one is group delusion. We—politicians, physicians, and patients—have continually refused to accept exactly how expensive modern medical care is.

The first decade of medicare, from 1970 to 1980, was comparatively easy to support. The economy was buoyant, there were no liver or hip transplants, and the population was still smoking and dying at the expected rate.

The second decade of medicare, from 1980 to 1990, saw an explosion of technology and procedures that was incredibly beneficial to patients, but prohibitively expensive to the taxpayer.

Governments of every political stripe were unwilling to disclose these costs to the public, and continued to promise free, all-encompassing health care while borrowing astronomical amounts to provide it. Thus was born the Cadillac health-care system on the Chevrolet income, using borrowed funds to make up the difference.

Physicians were just as guilty as everyone else at this time. We stuck our heads in the sand by not telling anyone how much this state-of-the-art medicine was costing. There are no heroes in this story.

Reality hit home in the early 1990s. Finance ministers, finally realizing that they could not sustain such costs any more, started cutting funding for health care. However, they were very careful to do this without telling the population what they were doing.

Health-care administrators are not foolish. They cut back on services that would have the least impact on the voting public. They knew that more than 80% of health-care resources are eaten up by less than 20% of the population, and that 20%—the very young, the very old, and the poor—don’t usually vote.

Strategically, the only services that had to be provided with no delay were emergency services and the three sacred Cs of medicare:

• Children, because parents are a lot more willing to fight for their kids than they are for themselves. 
• Cancer, for obvious reasons. 
• Cardiac care, because males between the age of 45 to 65 get cardiac disease. From which population group come the most lawyers, politicians, contributors to political parties, and physicians, until the significant increase in female physicians over the last 10 years.

We are now into the year 2000. I am frightened about what is going to happen over the next 20 years and beyond as baby boomers, including myself, reach the age where we will need the very services we are talking about.

About 6 years ago, politicians in Canada listened spellbound to such university health-care gurus as Robert Evans and Michael Rachlis. Needless to say, these gurus were not well versed in actual patient care nor apparently in the necessary ratio of health-care providers to patients, nor even in the projected increase in elder care requirements.

The gurus stated that the way to control health-care costs was to cut the number of doctors and nurses entering university. This was manna from heaven to the politicos, who could curb expanding health-care and secondary-education costs in one fell swoop. They jumped at the opportunity.

Less than a decade later, we have no nurses for the ORs or the ICUs. In the next 5 years, we will have no doctors either. The average age of a general surgeon in Canada is 57. The average age of an ENT surgeon is 55. We have nobody in the system to replace them.

Because of government policies, in the next 5 years here in Victoria, we will probably not have a neurosurgical service. If my daughter sustains a head injury, she will be transferred to Vancouver, or perhaps Seattle.

In Canada last year, 10 residents in neurosurgery completed their exams. Only three bothered to take out Canadian certification. The rest decided they could not work in the present Canadian environment.

Similar shortages are going to happen within every physician-based service in the province. To compound the problem, the current political climate does not even recognize the value of the physicians currently in the system.

Instead of immediately increasing resources to allow our children the opportunity to get an education and fill the needed vacancies in the health-care system, the current policy is to recruit foreign-trained nurses and physicians, usually from Third World countries. What a cynical and dishonest policy this is. We cannot train our own children because we will not fund the education system as our parents did in the past. We will try, however, to entice personnel from other countries who have provided the training opportunities for their citizens and can least afford to lose this valuable resource.

I am very pessimistic about where health care will be in even the next 10 years. We will no longer enjoy the health-care system our parents wanted and worked hard to institute. Unless drastic changes are made, and soon, we will have the same health-care system, or lack thereof, as they did back in those Dirty Thirties.


Dr Doty is the president of the SSPS and an otolaryngologist practising in Victoria.

David Doty, MD. Facing the true cost of medicine. BCMJ, Vol. 42, No. 5, June, 2000, Page(s) 247-248 - Editorials.

Above is the information needed to cite this article in your paper or presentation. The International Committee of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.

About the ICMJE and citation styles

The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.

An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors.

BCMJ standard citation style is a slight modification of the ICMJE/NLM style, as follows:

  • Only the first three authors are listed, followed by "et al."
  • There is no period after the journal name.
  • Page numbers are not abbreviated.

For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit www.icmje.org

BCMJ Guidelines for Authors

Leave a Reply