AMONG CANADIAN DOCTORS, a forty-two-year-old Saskatoon general practitioner named Sam Wolfe is probably the most intimately and painfully acquainted with medicare — the Orwellian contraction of universal, compulsory medical-care insurance — and the most devoutly certain of its civilizing effect on his own profession and on society.
Sam Wolfe has lived with the idea of national health insurance for as long as he has been in medicine. He entered the University of Toronto's Faculty of Medicine in 1945, the year that a federal Liberal government, planning the nation's postwar reconstruction, proposed comprehensive health insurance, under provincial administration, as an essential element of social security for all Canadians. The national plan failed for lack of agreement on financial arrangements between the federal and provincial governments.
But by 1950, when Sam Wolfe graduated, the CCF government of Saskatchewan had introduced publicly administered, tax-financed hospital insurance and was committed to the insurance of doctors’ services as well. Dr. Wolfe went to Saskatchewan from his native Ontario to join in the experiment.
Now, with medicare once again an urgent national issue. Dr. Wolfe can predict, from his own intense personal experience, not only the conflict that will immediately ensue, but the changes his profession must accept, if medicare spreads across Canada.
Dr. Wolfe's own career is a case history of the jarring consequences of medicare in Saskatchewan, the working model for a national plan. For his active support of medicare — he has served from the start on the government commission that administers Saskatchewan's 1961 Medical Care Insurance Act — Dr. Wolfe has been branded a heretic by his own profession, ousted from the faculty of the University of Saskatchewan's College of Medicine and isolated, as if he were contagiously diseased, from ordinary social as well as professional contact with most of his colleagues.
But Sam Wolfe has done more than survive; he has demonstrated, in the Saskatoon clinic he directs, how, within the framework of a medical-care insurance plan, medical practice can be radically reorganized. His heresy is in seeing medicare as the instrument, not the end, of what he calls medicine's industrial revolution.
On July 1, 1962, when most of Saskatchewan’s doctors went on strike against medicare, their mistake, according to Dr. Wolfe, was precisely the same as other workers have made when confronted with innovation in their industries: they tried to wreck the machinery instead of learning to work with it. He believes that doctors in other provinces will not make the same mistake.
The national medical-care insurance plan, which the federal government recommended on July 19 as a start toward comprehensive national health insurance, is basically the same as Saskatchewan's. Each province, to qualify for a federal contribution. must imitate the Saskatchewan pattern of government-operated, tax-supported compulsory insurance, providing a full range of medical services for all citizens. The Canadian medical profession. to fight medicare, must fight the fact of medicare's conspicuous success in Saskatchewan.
Only three years after medicare was set in motion, inauspiciously in the midst of battle, it works so well in Saskatchewan that no government would dare tamper with the machinery except to install more. Paradoxically, it was the defeat of the CCF government in 1964 by a Liberal Party that identified itself with free enterprise, that made medicare secure. When the new government could not be persuaded to dismantle the machinery of medicare, the province's doctors had to come to terms with it.
MEDICARE COMMISSIONER Wolfe points out that none of the fearful consequences of medicare that doctors predicted in 1962 — staggering costs, cumbersome administration and deterioration of medical services due to overuse, bureaucratic meddling and damaged doctor-patient relationships — has come to pass. Administrative costs of the Saskatchewan plan, according to Dr. Wolfe, are the lowest of any medical-care insurance scheme in Canada. He reports that demand for doctors' services has shown only a discreet rise in the last three years. Doctors' incomes have risen — medicare does away with bad debts — at no cost to their independence. Patients have the same freedom as before to choose their own doctors.
Medicare, Wolfe emphasizes, is not state medicine, as his colleagues originally interpreted it to be. In his experience, it's an effective, economic alternative to state medicine, a means of making medical services universally available, without interference in the way they are dispensed or used.
Dr. Wolfe suggests that for a cost comparison between publicly administered medical-care insurance and a private-enterprise system, Saskatchewan consumers have only to look next door to Alberta, where an average family of four pays about one hundred and sixty dollars for less comprehensive coverage by commercial companies than is available at one third the cost in Saskatchewan. Annual premiums — twelve dollars for a single person: twenty-four dollars per family — take care of about one quarter of the total cost of medicare in Saskatchewan. A medical-care sales tax of one and a half percent and a surcharge on income tax cover the big remainder. A family of four with an income of four thousand dollars pays approximately twenty-four dollars in sales tax, ten dollars in surcharge, plus premium, for a total of fifty-eight dollars per year. That amount is prepayment for a full range of doctors’ services, excluding only cosmetic plastic surgery.
How comfortable Saskatchewan doctors have become with medicare is demonstrated by the fact that few exercise the option, which they fought for in 1962, to practise outside the plan. Only six percent of all claims made on the Medical Care Insurance Commission last year were by patients whose doctors comprised the small minority still declining to acknowledge the existence of the government agency.
But Saskatchewan doctors, Sam Wolfe insists, still have to come to terms with their industrial revolution. For all the marvelous advances that have been made in medical science and technology, most doctors — not only in Saskatchewan but across Canada — continue to operate, in Wolfe's phrase, “like nineteenth-century laissez-faire private entrepreneurs in little single-handed offices,” complaining of overwork and yet competing against each other instead of co-ordinating their resources. The economics of organized medicine, according to Wolfe, is strikingly at odds with the aim of modern medicine, which is to maintain society in health, not merely treat its sick. Medicare, by revealing no more than how doctors are paid, has uncovered the source of this conflict.
The basic fault, as Medicare Commissioner Wolfe sees it, is in the fee schedule set by the profession's governing body, the College of Physicians and Surgeons, which provides far more incentive to the performance of technical procedures and surgery than to the practice of preventive medicine. The distribution of medicare payments in Saskatchewan reflects the disparity between the value placed on procedure and the value placed on care of the whole patient. Surgery comprised only four percent of all services supplied in 1964 but accounted for twenty-five percent of all medicare payments. Specialists provided 21.8 percent of services but received 36.1 percent of payments.
AS FOR THE LOW MAN in organized medicine, the general practitioner, his crucial role as the original diagnostician goes relatively unrewarded. The fee schedule for his services actually discourages careful history-taking, thorough examinations and counseling, although these are at the core of his professional responsibility. From his own experience as a GP. Dr. Wolfe explains. “Under our present fee schedule I get paid seven dollars for doing a history and physical examination that should occupy me for almost an hour. For squirting cortisone into a knee joint, which takes forty seconds, I earn eight dollars. If I assist a surgeon during an operation by simply holding retractors — a task that requires little or no medical training — I can earn twenty-five dollars an hour, if I chose to do three tonsil operations, taking an hour’s work altogether, I would be paid one hundred and twenty dollars.”
Dr. Wolfe suggests that a reformed fee schedule is essential to the sound operation of a national health plan.
Under the plan proposed by the Royal Commission On Health Services, the medical profession would lose its monopoly on fee - fixing on the grounds that such a monopoly is “incorrect and unrelated to the mores of our times." The provincial government medicare agencies would he given the power to negotiate fees with the profession.
But the Saskatchewan College Of Physicians And Surgeons still insists — as does the Canadian Medical Association — that the establishment of fee schedules is the profession's sacred right. So far no machinery for negotiation between the college and the Saskatchewan Medical Care Insurance Commission has been set up.
Sam Wolfe persists in his belief that medicare not only permits but requires the reorganization of medical practice. In the Saskatoon Community Health Services Medical Clinic, which he directs, Wolfe and twelve colleagues — seven other general practitioners, a radiologist, a psychiatrist, a surgeon and a gynecologist, as well as a medical social worker — are demonstrating one way it can be done. Using a new approach to the payment of doctors and a redefinition not only of the role of the general practitioner, but of the relationship between doctors and the consumers of their services, their method may prove to be more controversial than was medicare itself.
The facilities and equipment of the Saskatoon community clinic are owned by some two thousand families of consumers organized into a co-operative which rents the facilities to the doctors on a nonprofit basis. The doctors send all bills directly to the Medical Care Insurance Commission, then pool their incomes and are paid, each according to his training, experience and time spent on the performance of his skills, whether they are in surgery or the taking of a case history. Since one need not join the co-op to use the clinic, in the three years since it went into operation, more than thirteen thousand Saskatonians have used its facilities.
The clinic is designed, Dr. Wolfe reported recently in The Canadian Medical Association Journal, not as an exercise in social reform, but for the “enlightened self-interest of doctors." He explained: “In group practice each doctor tends to have more time to himself, is able to take holidays on a regular planned basis and is able to take time for postgraduate work and for attendance at medical conventions without jeopardizing his income or the care of his patients. Unnecessary and costly duplication of facilities and gadgets may be kept to a minimum. There is less competition for the patient’s illness dollars, since income is pooled and shared. Most important of all, in high-quality group practice the physician becomes accustomed to professional supervision and to a review of his work by his colleagues . . . The judgment of one’s medical peers may be one of the most important factors in determining the quality of professional performance of the individual physician."
Sam Wolfe's concept of a family doctor is the end-product of his own experience, not only as a doctor but as a patient. He spent most of his seventeenth year in the Toronto General Hospital, encased in plaster, from head to toe, following surgery on a diseased spine. He was a charity patient and two things impressed him profoundly. One was the "superb technical care" he received. The other was the pervading unconcern for the boy in the cast. “At no time.” in Sam Wolfe’s experience as a patient, "did anyone care about me as a person, what I thought lying there, or what I'd do afterward.” By the time he left the hospital he had planned the pattern of his life: he would be a doctor, concerned about the whole care of his patients. He had also learned to be comfortable with the fact that he was a congenital nonconformist.
Since then medicine has been Sam Wolfe's life. He studied at the University of Toronto, interned at the Saskatchewan Hospital in Weyburn, and at the Regina General Hospital. Then he decided to settle in Saskatchewan, which "philosophically attracted" him. At first, he practised in the north — at Smeaton, and then Porcupine Plain where he worked part-time on a fee-for-service basis and part-time as a salaried employee of the rural municipality and was satisfied that the latter arrangement worked well both for the doctor and his patients. He also served as a University of Saskatchewan preceptor, a function involving on-the-spot training of senior medical students in the problems of the rural practitioner.
The hope: a new breed of GP
It was his experience as a preceptor that persuaded Dr. Wolfe to resume his own education. He took a year's postgraduate training in psychiatry at Saskatoon’s University Hospital and then, on a Rockefeller Foundation fellowship to Columbia University in New York, two years of training in public health. In the summer of 1961, Sam Wolfe, MD, Dr. PH, returned to Saskatchewan to set up a family-care teaching unit in the College of Medicine. His responsibility was to be the training of a new kind of family doctor — a new breed of GP, who would be a specialist in his own right. His would have been the first family-care teaching unit in any Canadian university. But the medicare crisis intervened.
Saskatchewan Dean of Medicine, Dr. Wendell Macleod, resigned. Dr. Macleod, who was in favor of medicare, had approved Dr. Wolfe’s appointment to the Medical Care Commission, when it was set up in January 1962. His successor, Dr. Robert Begg. interpreted Wolfe’s participation as a political undertaking and was embarrassed by it.
In the summer of 1962, after Wolfe had organized an airlift of British doctors to serve in Saskatchewan during the doctors’ strike and requested a leave of absence from the university to serve himself, he was warned that his activity was jeopardizing his future as an academic. Dr. Wolfe resigned on the understanding that he would be permitted to teach part-time in the Department Of Preventive Medicine. When he subsequently applied for such a position, he was told that none was vacant. Since that time Dr. Sam Wolfe’s family-care teaching laboratory has been the Saskatoon community clinic.
The Saskatoon clinic was the second of thirteen medical co-operatives to be set up in Saskatchewan during the medicare crisis. Those in rural areas are still having trouble recruiting and keeping doctors. Practising in opposition to organized medicine they find to be a lonely enterprise. But the six clinics located in large centres of population are growing strongly. Their doctors have room to live and work comfortably, despite the continued opposition of their colleagues in private practice to the clinics’ co-operative organization and aims.
Dr. Wolfe, on rounds in Saskatoon’s City Hospital, has grown accustomed to the sight of colleagues taking to the stairs in preference to sharing an elevator ride with the director of the Community Health Services Medical Clinic. He understands why some of his former friends, specialists, are cordial to him when they meet privately but decline to acknowledge his presence in hospital corridors. They depend for their referrals on the goodwill of the medical community. Dr. Wolfe is still not a respectable member of that community.
Is medicine above criticism?
A fastidiously groomed man, both physically and intellectually, he affronts his colleagues mainly by his refusal to regard medicine as arcane and therefore immune from the ordinary problems and even immoralities of business organizations, which are also providing services. Now that the public is paying for doctors’ services, it has a right to expect those services to be organized economically and efficiently, Wolfe bluntly insists. He has less trouble communicating this heresy to the provincial Minister Of Public Health, D. G. Steuart, himself a former businessman, than to his own profession.
Sam Wolfe takes consolation from his conviction that “frictions and disagreements between doctors, while disturbing, are not necessarily unhealthy. After all, the ways of paying doctors, the relationship of doctors to one another and to society in general are not regulated by immutable laws. They are constantly changing and will constantly change in the future. Both society and medicine as a part of society have undergone overwhelming changes in the past hundred years. These changes have required, in turn, rapid changes in patterns of thinking by both the profession and the general public; little wonder that some of this thinking has created anxieties about both the present and the future.”
Sam Wolfe, from his own experience in Saskatchewan, is convinced that Canadian society and the Canadian medical profession will make the necessary accommodation to the spread of medicare and the changes that will come in its wake. His own survival as a practising medical nonconformist is what makes him optimistic.