My last rant

I expect that this will be my last opinionated rant for the editorial pages of the BCMJ. I joined the Editorial Board back in the old days when Dr Hardyment was the editor, and I  stayed on this most enjoyable of medical committees until my retirement a year or two ago. I was called back last year to fill in for Dr Day who was busy elsewhere. Dr Day is free, now, I believe, to resume his position on the Editorial Board, and so I must say farewell once again. I feel like an aging diva who keeps having final, final farewell tours.

The Journal has adapted to the changing needs of the profession over the years.

The focus has always been to be useful to the practising family physician. One of the most practical innovations was the soliciting of theme issues. Many of these issues resulted in a flurry of requests for reprints in the days before they could be downloaded from the web.

Some articles that are sent in are abstruse and aimed at a small, specialized audience. Some are of such a specialized nature that a simple (ex-) surgeon such as I finds difficulty in understanding, much less editing, them. Some of these articles are sent out for external review and a few find a place in our Journal. Nevertheless the major part of the Journal is devoted to practical and informative material with the occasional humorous or historically interesting piece.

The pleasure of attending Editorial Board meetings is due largely to the erudite, witty, and intelligent editor and other Board members, and also to the hardworking staff and the managing editor, Jay Draper. It is also fun to see each month what the cover design from the incomparable Jerry Wong will be.

As I look back and admire the way that the BCMJ has evolved over the years, I see a sharp contrast to the way our health system has stagnated and ossified. When the Canadian system came into being it could be described quite fairly as “the envy of the world.” Now it might be the envy of the average peanut farmer in Burkina Faso. What has gone wrong?

As I see it the problems stem from two areas: government monopoly and us, the medical profession. 

I always thought that the aim of the physician or surgeon was to cure ill health, not to make as much money as humanly possible. The 3-minute “consultation” devoid of history taking or examination satisfies only the banking industry and possibly the pharmaceutical companies. I do sympathize with the problem of crippling overhead costs and the feeling of being undervalued, but surely there must be a different and better solution.

The government monopoly and its fear that any change to the system would be political suicide stifles innovation and improvement. The Canadian public believes the canard that the system cannot be changed without destroying it. So the public tolerates interminable and costly waits for diagnostic tests and for surgical procedures and for an appointment with their family physician, if they have one. 

In any other rich country the public would be up in arms, or at least hounding their parliamentary representatives for such mismanagement.

There must be a better way.

The political mindset is limited to the short term, particularly if there can be the appearance of tax money being saved. This explains the closure of Riverview, which ejected the impaired and incapable onto the streets instead of refurbishing the institute and up­dating the care at that site. Hence the closure of other hospital beds and the limiting of the number of operating and emergency rooms, which has produced the chaos we know today.

Once I sat in on a committee of local mayors who were debating the need for long-term-care beds. Their consensus was “If we build them they will only fill them up… so we won’t build them.”  

There must be a better way.

The burgeoning bureaucracy and the plethora of managers who eat up health dollars before they can reach the patient is one part of the problem. Yes, health care is more complex these days but surely we can get by with fewer clipboards.

The block funding of hospitals produces undesirable effects. The hospital is penalized if it goes over budget or if it is under budget. The result is limitation of patient care (those pesky unpredictable patients) and panic spending as the end of the fiscal year approaches. 

There must be a better way.

Lip service is paid to prevention of the most basic kind. How about giving local cafes and restaurants a tax break if they provide breakfast and lunch services to local schools? How about really increasing addiction rehabilitation services? In spite of all the money that has been poured down the sink in the Downtown Eastside of Vancouver there has been little or no improvement in the health of those who live there.

I grant that there have been some outstanding programs developed in our province, such as cancer care and HIV care in Vancouver, and when the squeaky wheels are really loud there have been improvements in some types of orthopedic services and cardiac care, but too often the increase of activity in one area comes at the expense of other equally important programs. 

There is some hope that the move toward coordinated protocols for some chronic diseases will be an improvement. But these seem to be baby steps when the whole system needs a good shake-up… or maybe a good editor.

There has to be a better way… but “How long, O Lord, how long?”

Patricia M. Rebbeck, MB, ChB, FRCSC. My last rant. BCMJ, Vol. 50, No. 7, September, 2008, Page(s) 355 - 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.

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