Medicine, the media, and politics

We could be forgiven for being bored with politics. In a timeline of just a few months we have lived through Canadian and United States federal elections, provincial by-elections, and municipal elections. BC will soon face a provincial election. Having spent years immersed in medical politics (which some believe is even more challenging than the real thing), I am convinced that doctors must become even more politically active.

There are downsides to getting involved. I have experienced a full range of attacks, including demonstrations, lawsuits, verbal insults, and nasty letters. I have been called a variety of different names (the devil, the destroyer/Darth Vader of health care, the elephant in the room, Dr Profit, and some others that I cannot put into print).

Physician-directed patient services in Canada are largely government funded and health care costs are ap­proaching 50% of provincial spending. In aiming to excel as clinicians, educators, and researchers, we must work to expand our leadership roles in health policy, planning, administration, and politics. A May 2008 Angus-Reid poll placed doctors—with a 94% rating—number one in terms of professions that the public respect and trust. We must build on and leverage that trust with governments.

The partisan politicization of health care is not healthy. Four-year electoral cycles discourage long-term planning that is necessary for sustainability. Governments prefer positive short-term results and returns. Reforms leading to long-term improvement that might reflect on a future rather than the present government are less appealing. We rightly preach that denial of access should never be based on ability to pay. The status quo, which is to deny care based on governments’ failure to deliver, is equally unacceptable.

Neither of the main federal parties in Canada has taken a leadership role in health care. In the last federal throne speech, I listened as the topic of health care was virtually ignored. Not to be outdone, the Liberal Party of Canada sent out a pre-election questionnaire in which they identified “today’s issues of crucial significance.” Of 16 questions in their poll none related to health care. Yet voters consistently place health as a top concern at election time, and a recent Pollara poll revealed that 68% of Canadians believe we need major reform. In the past, governments have fought and lost elections on health care. The timing is right to win on this very issue. With 68% support, no political party need fear the opposition. There wouldn’t be any. Governments may worry that a platform of health care reform would be a little controversial, but with polls in support, I would not rank it as overly courageous.

We all support funding essential care for all, but it is simply wrong to make unrealistic promises. The World Health Organization has stated un­equivocally that when services are to be provided for all, not all services can be provided. This means we must come to terms with a societal question as to what we include in the “basket” of publicly funded services. The terms “medically necessary” or “medically required” are used widely in Canadian legislation, but have never been defined.

Physician loyalties must not be influenced by the fact that we and the services we deliver are almost exclusively government funded. Benchmarking for patients on wait lists is one example where we must tread cautiously. I do not know a single ortho­paedic surgeon who believes a patient awaiting a hip replacement should suffer in pain for 6 months. Yet, because many waited much longer, we bought into that time line. We put the system ahead of the patients and accepted compromises that did not represent best practices.

Canada’s health scheme should no longer be constrained by the outdated Canada Health Act (CHA). Its principles of comprehensiveness, accessibility, universality, portability, and public administration are, with the exception of the last, widely ignored. Some consider the law Orwellian. Initially designed to set a baseline level of care, below which no Canadian would fall, the CHA has been used to set a ceiling above which none shall rise. It was introduced on April Fool’s day, 1984, and was based on the Sas­katchewan Medical Insurance Act of 1961. Unfortunately, but perhaps not accidentally, Tommy Douglas’s eight principles were whittled down to five (excluded were efficient, effective, and responsible). The last year that a grand slam tennis tournament was won with a wooden racquet was 1984. Tennis has modernized, evolved, and moved on. It’s time for the CHA to follow suit.

My year as CMA president was demanding, but one of the great rewards was the travel and the camaraderie with colleagues in both urban and rural communities across all provinces and territories. In the long history of the CMA (it is just 3 months younger than Canada), I was the first orthopaedic surgeon to be elected president. I was occasionally roasted rather than toasted, facing introductory remarks like, “What’s the difference between an orthopaedic surgeon and a carpenter? Answer: A carpenter can name two antibiotics.” After the fun and socializing, the meetings turned to the serious and urgent business of improving health care delivery in Canada, and I found there was a remarkable consensus among doctors on how to achieve this.

Canada’s system remains in a time warp, spinning in a vicious circle, in which extreme rationing leads to limited access, reductions in workforce, limited technology, long waits that negatively impact the economy, re­sulting in funding pressures that force rationing. We must break that circle with measures that stimulate competition, efficiency, and accountability and we must recognize the need for sustainability. Canada must em­brace and encourage private sector investment, while maintaining a system where no person is denied necessary care based on their ability to pay. We must borrow from the best practices of countries that have achieved that goal.

Doctors must increase their political activity as they continue to provide a reality check for the public, politicians, and the media. For the European Consumer Powerhouse to rank Canadian health care delivery in 2008 as last alongside 29 European countries in value for money, and 23rd overall in quality, should be a wake-up call. We are now beginning to see improvements from our efforts, but the momentum must continue. With leadership and a united profession we will achieve our goal of converting a dysfunctional scheme into an excellent patient-focused and physician-directed Canadian system.

—BD