QUICK NOW: WHAT’S YOUR DOCTOR’S FIRST NAME?

If you can answer that question, you’re part of a vanishing generation. Increasingly, medical care is coming to involve a team of specialists, batteries of expensive machines, and a hurried encounter with someone you’ve probably never met before. Is this trend desirable? Or is there still a place for the old-style family physician? Doctors themselves can't agree. Until they do, your chances of getting the best medical care — or even a hospital bed — are lower than they should be

ALAN EDMONDS April 1 1967

QUICK NOW: WHAT’S YOUR DOCTOR’S FIRST NAME?

If you can answer that question, you’re part of a vanishing generation. Increasingly, medical care is coming to involve a team of specialists, batteries of expensive machines, and a hurried encounter with someone you’ve probably never met before. Is this trend desirable? Or is there still a place for the old-style family physician? Doctors themselves can't agree. Until they do, your chances of getting the best medical care — or even a hospital bed — are lower than they should be

ALAN EDMONDS April 1 1967

QUICK NOW: WHAT’S YOUR DOCTOR’S FIRST NAME?

If you can answer that question, you’re part of a vanishing generation. Increasingly, medical care is coming to involve a team of specialists, batteries of expensive machines, and a hurried encounter with someone you’ve probably never met before. Is this trend desirable? Or is there still a place for the old-style family physician? Doctors themselves can't agree. Until they do, your chances of getting the best medical care — or even a hospital bed — are lower than they should be

ALAN EDMONDS

AT A TIME WHEN medical science can do more for what ails us than ever before we, the patients, are asking with disturbing frequency, “Can I trust the doctor?” And we ask the same question about nurses, hospitals and other medical people. It hasn't yet reached the proportions of a crisis of confidence, but it is a symptom of a largely unrecognized revolution that's quietly agitating the world of doctors, nurses and hospitals — the people in whose hands we place our lives.

Doctors, who sometimes seem unable to agree whether a toenail is ingrown or not, currently display an alarmingly unanimous belief not only that Canada is perilously short of doctors, but that many ot those now treating patients — general practitioners particularly — are badly or inadequately trained and not necessarily good at the job. Nurses, whose principal off-duty concern has long been the alleged poverty level ot their pay, are beginning to show even more concern at Canada’s dependence on immigrant nurses, and the way nurses are trained, then misused. And the nation's hospitals, faced with waiting lists of thousands, are privately plagued by the question: “Are hospitals a safe place to be sick?”

The medical profession is split with bitter wrangling over whether Canada should stake its future health on the general practitioner or the specialist. Nurses are muttering rebelliously about “slave-labor' training which has them doing menial jobs in hospitals and which may be the real reason for the socalled nurse shortage (Canada actually has a better nurse-to-population ratio than most other nations). And the hospitals are openly admitting they spend too much time on the chronically sick, the aged and the convalescent while thousands of the curable go begging for attention, suffering physical and psychological agonies while waiting for it.

Somewhere at the eye of this hurricane we patients sit. a little frightened, not as confident as we once were that doctors, nurses and hospitals really are good for us, and only vaguely aware of this largely unco-ordinated revolution that’s swirling about our heads and being conducted in our name.

Two months of studying the problems that beset the world of medicine have simply shown me that there's an alarming lack of agreement about where this revolution is leading, or should lead, and about the best way to harness its energies. Everyone agrees new training methods for doctors are needed and a new concept of medical practice must be evolved. Yet medical educators and doctors’ organizations can’t agree on how to produce the doctors and what this new concept should be. So they’re currently spending a billion dollars, a billion dollars, on new and improved health-education facilities — and can’t agree whether they're spending it wisely or not.

Anyone who has tried to get a doctor to make a house call lately has found evidence of the doctor shortage, but it’s the doctors themselves who are most alarmed at their own shortcomings: they sponsored one survey which suggests that around a quarter of the nation’s estimated 10,500 GPs are so incompetent their patients are “probably exposed to severe risk.”

This, along with the numbing pace of scientific discovery and the upheaval in social and moral standards, has split the nation’s doctors into two camps. One, which could be called the right wing and is supported by GPs, doctors’ organizations and medical schools in western Canada, says that a new-style GP, trained as a specialist in family medicine, should be the pivotal figure in Canadian health services. The other camp, the left wing which draws most of its support from specialists’ organizations and in eastern Canada, believes the GP is obsolete and that specialists in group-practice clinics should take over the job of providing basic medical care for us, the patients. This left wing argues that / continued on page 93

continued on page 93

If teams of specialists like the one at left do replace the old-style GP, what do we lose? See overleaf

WHAT’S YOUR DOCTOR’S FIRST NAME? continued fron, page 19

“People used to ask, ‘Can you help me?’ Now it’s, ‘Cure me.’”

no one man can treat the whole human being now that we know so much about the component parts of the body, and so specialists must dominate the medical profession. Both sides argue — convincingly, too — that the other's road leads to disaster for the nation. Both also agree — and this is what's alarming — that the average medical graduate of today is not ready to go into solo practice, though he often does.

There are equally disturbing conflicts among nurses and hospitals. And everyone knows, or thinks he knows, of a case in which someone suffered or even died because some doctor, hospital or nurse bungled. But the doctor is the single most important factor in any medical treatment, and so the crumbling of his once invincible image is the most significant evidence of medicine's underground revolution.

THE PRESENT TURMOIL, really began when the Hall Commission on Canadian Health Services, set up in 1961. found that although GPs handle 85 percent of the nation’s medical problems, more than 50 percent of Canada’s doctors were specialists. “We knew we were short of family doctors, but until then it wasn’t generally realized that the shortage was quite so bad,” says Dr. Donald Rice. -Executive-Director of the College of General Practice of Canada.

The reasons for this GP-specialist imbalance are manifold. Faced with the need to cram a burgeoning mass of scientific knowledge into a traditional six-year course designed to produce the doctor of 50 years ago. medical schools have become dependent on specialists and scientist-teachers. By a process of osmosis, students become specialist-oriented, often scorning general practice as somehow unworthy of their talents.

Their training also makes them oppressively aware of how little they’ve learned in six years; medical schools by their own admission have been producing graduates ideally suited for specialist training, but not for practice as doctors. Thus the new MD often feels inadequately equipped for general practice and takes post-graduate training becatise it’s easier to keep up with scientific progress if you're principally concerned with, say, the heart or the psyche or the lungs. Those graduates who do become GPs are, says Dr. Rice, either “very brave men, hoping to pick up sufficient training as they go along, often at their patients’ expense,” or the inefficient, the bad student and the less competent.

Family practice is also unattractive because there’s already a GP shortage and the new man in the field is rapidly overworked, while the specialist often makes more money and has a more comfortable life. Besides, the public is expecting more from doctors as advances in medical science—Dr. Michael dcBakey’s heart - replacement pump, for instance — lessen the death rate of one disease after another. A Regina GP speaks for most of his fellows when he says, “People used to ask, ‘Can you help me, doctor?' Now they demand, ‘Cure me.’ They've

read so much about scientific discoveries they expect miracles and get mad when you can’t deliver. To keep pace with the demand, you need a subscription to Reader's Digest.”

The same man complains about people refusing to accept responsibility for their personal problems and taking them to the doctor instead, a com-

plaint reinforced by a Winnipeg GP who tells how, in January, middleaged parents demanded he prescribe contraceptive pills for their 14-vearold daughter “to save us from worrying.'’ He. in turn, says that in Canada almost everyone comes from somewhere else, and the G P's load is made heavier because people, young

parents particularly, don't have grandparents living with them, as they once did, and so when they or their children develop minor ills, they turn to the family doctor for advice.

And then the public expects the doctor to play God. A harassed GP in a small Quebec town says. “As people’s faith in God diminishes, you find more and more people in the waiting room with problems that 10 years ago they’d have taken to their ministers or maybe their parents. Sometimes they come

WHAT'S YOUR DOCTOR’S FIRST NAME? commue,I

We need 1,300 new doctors a year. Last year’s total: 888

straight out and use your office as a confessional, but usually it turns up as a psychosomatic illness. I had a woman the other day who thought her irregular menstrual cycle was a cancer. When we proved it wasn’t and she was back for the fourth time, it turned out her husband was playing around with another woman and her

problem was emotional, not physical.”

If that’s a problem in Quebec, where the church is strong, it must be vastly magnified in the other, less churchoriented parts of Canada.

But the specialist-GP ratio isn’t the only problem, as the Hall Commission’s statistics revealed. The doctor-

patient ratio, it found, was one to 857 people, which meant that Canada was worse off for doctors than 13 other industrialized nations. At that, many of our doctors are in industry, work for insurance companies, or are teachers, and so aren’t actually in practice.

The unhealthicst doctor-patient ra-

tio is one of 1,590 in Newfoundland, and the best is one to 750 in British Columbia. Even there, because most of the doctors are clustered in the Vancouver area, the College of Physicians and Surgeons says it could find jobs for 125 doctors—if they were prepared to work in the hinterland. At New Denver in the Kootenay Valley, for instance, the 22-bed hospital, at the time of writing, had been doctorless for three months, and had scant chance of finding another doctor to work in the town. Emergencies there were being dealt with by a doctor who lives 35 miles away, and who has been advertising in vain throughout North America and the U.K. for four years trying to attract an assistant.

Even to maintain the far-from-ideal one-to-857 doctor-population ratio, Canada must have 1,300 new doctors a year. But the nation’s 13 medical schools produced only 888 last year, though this is increasing: last year, for instance, the schools enrolled 1,230 new students, some of whom will drop out. Immigrant doctors are supposed to fill the gap, but their numbers have been falling off lately. Besides, in one recent year more doctors emigrated to the U.S. than graduated from our medical schools. One new medical school opened in Quebec last year, another will open before 1970, two more are planned and existing schools are expanding. But even the Quebec school won’t start graduating students for at least six years, and in the meantime Dr. John Crawford, federal Deputy Minister of Health and Welfare, admits, “The doctor shortage is alarming.”

For patients: “serious risk”

But, serious as the statistical situation appeared in 1960 and 1961, the polarization of the right and left wings of medicine — the proand anti-GPs —did not take place until after the publication in 1962 of a book-length report, The General Practitioner, by Dr. Kenneth Clute, of Toronto. Clute had spent five years studying a sampling of Ontario and Nova Scotia general practitioners and decided that only half the Ontario doctors and a quarter of those from Nova Scotia, mostly the younger men, practised “satisfactory” medicine. Of the remainder, he implied that 21 percent in each province were mediocre, and bluntly said a quarter of Ontario’s doctors and half of Nova Scotia’s “caused grave misgivings [because] the deficiencies in these men’s practices were thought likely to expose their patients to serious risk.” While Clute’s findings are based on a sampling of fewer than 100 GPs, they do suggest you can’t trust a quarter of the nation’s family doctors.

Both proand anti-GP camps say that, unless their approach is adopted, the inadequacies of our health services could reach crisis proportions. But we’ve got a crisis already. While most of the four to five million Canadians without medical insurance of any kind can be presumed to lack the best medical attention available, the present lack of manpower and competence means that many of those who can afford the best can’t get it either.

In the main, organized medicine— medical associations, colleges of physi-

WHAT’S YOUR DOCTOR’S FIRST NAME? continued

“If medicine becomes cold, inhuman, heaven help us all”

cians and surgeons and other doctors’ organizations — have thrown their weight behind several largely uncoordinated moves to rehabilitate the GP. It's a predictable reaction of a traditionally autonomous and autocratic profession fighting to retain that independence in an increasingly interdependent world. Certainly, the colleges of physicians and surgeons are generally unenthusiastic about any kind of co-operative group practice.

Even so, they recognize that a new kind of GP is required if the breed is to be preserved. The old concept was valid, say, 30 years ago, when one man did stand a chance of absorbing at least more than half the known medical science, and could competently handle most of the more common medical-surgical problems for which treatment techniques did exist. But more than three quarters of ihe medical knowledge and techniques practised today have been developed in the past 15 years — and half of that will he out of date in the next 10. The inability of any one man to absorb and stay abreast of this awesome body of knowledge means that, even now, some medical educators are talking about the possibility of limited licensing, under which a doctor would be permitted to practise only in a specified field, and would not be allowed to treat anyone for any ailment outside that specialty.

Unhappily, the right-wing rehabilitators of the GP themselves cannot agree on just what kind of doctor this new-style GP should be; just what might be demanded of him in practice; whether or not he should be permitted to perform surgery; and, most important, how he should be educated. A consensus would suggest that, ideally, he would be a man trained to recognize diseases and ills but not necessarily to treat all of them himself; a man trained in both the science and art of medicine, yet with sufficient humility — not a notable characteristic among doctors — to admit his limitations and quickly refer those who need it for specialist treatment.

More important, he should regard himself as part of a clinical team and hand over much of what has long been considered the doctor’s exclusive work to nurses, psychiatric social workers, public - health nurses, and other paramedical personnel. In Sweden, where the doctor-population ratio is as low as Newfoundland’s, medical services are excellent, largely because these paramedical personnel have taken over in some of the doctors’ traditional preserves—injections, bandaging, some midwifery, rehabilitation, social counseling, and giving treatments prescribed by doctors.

It is in the field of undergraduate education that the greatest disagreement exists. But the need for a revolutionary new approach of some kind was underlined by Dr. Clute’s finding in The General Practitioner that present undergraduate training is no guarantee that a young doctor “is ready to assume the full responsibility of an independent practice [although! circumstances may force him to accept responsibilities which are beyond

his capabilities.” Poor patient!

The right wing has no doubt about the need for the GP. Dr. Rice, of the College of General Practice, says, “First, you obviously must have someone who sees the patient in the first instance to decide whether he needs a specialist. And then it is accepted that somewhere between half and three

quarters of the cases a GP sees have nothing to do with the patient's physical welfare, but are largely caused by stress or tension or have their root in some other psychosomatic cause. And that means that if the doctor is to help them he has to know something of them, their work, family circumstances, the pressures under which they

live. The GP practises the art of medicine. The specialist often practises the art of looking for and treating one disease — and one only. If Canadian medicine becomes cold, hard, clinical and inhuman, heaven help us all.”

Or, as one Montreal GP says, “The orthopedic surgeon will always be a better orthopedic surgeon than I am. but I’m damned if he’s ever likely to he a better doctor.” Not all specialists are as heartless as Dr. Rice suggests.

continued on pape 96

WHAT’S YOUR DOCTOR’S FIRST NAME? continued

Does Canada need a new-style GP?

But a few months ago an unmarried coed in Halifax consulted a gynecologist about her pregnancy, when her real problem was how to tell her parents. The gynecologist was good for the pregnancy but did nothing about the parent problem, and so the girl now needs a psychiatrist more than a midwife. The core of the rightwing, pro-GP argument is that the GP would have been concerned at least as much about the psychological problem as with the pregnancy and would probably have helped solve it.

The most dramatic bid to rehabilitate the image of the GP in Canada came last September, when Dr. John Corley, a Calgary GP, launched a three-year postgraduate training course in general practice at the 1,000-bed Calgary General Hospital. It’s an attempt to treat family medicine as if it were a specialty. The course is being taken by eight graduate MD students who volunteered as guinea pigs, and the diplomas they will receive on graduation are at present largely meaningless.

“But we have to start somewhere,” says Corley. “We have to create a new kind of general practitioner whose speciality is people, not the bladder or the sacroiliac. The whole human is more important than the sum total of his parts.”

Corley's guinea pigs will take crash courses in all the specialities, with large doses of psychology and psychiatry, then practise under the eye of established general practitioners who,

says Corley, “will monitor the mistakes new doctors inevitably make, though usually they aren’t monitored.”

The Calgary experiment is controversial. Some doctors regard it with scorn, and it is argued that tagging three years onto the six-year MD course will only aggravate the doctor shortage, and make general practice less attractive to graduates. But because agreement that a new-style GP must be produced is widespread, the nation’s medical schools are under pressure to rebuild their curriculums. However, not all of them agree a newstyle doctor is needed — and even if they did, it seems unlikely they would agree just what breed of cat this new GP should be.

The University of British Columbia medical school is pioneering in the search for a new GP concept and has built a medical education centre where all medical personnel—doctors, nurses, physiotherapists, social workers and so on — will be trained together and learn to work as a team. There, firstyear students are taught by general practitioners as well as specialists, and learn a potpourri of practical psychology, interview techniques, the way to take case histories — in short, they're taught the bedside manner. This is done because the school found that scientific and laboratory-oriented training discouraged first-year students. But even at UBC tradition dies hard. For instance, students still spend

continued on page 98

WHAT’S YOUR DOCTOR’S FIRST NAME? continued

What they’re trying to find out: what’s a “good” doctor?

weeks of their biochemistry course producing neat diagrams of the molecular structure of Vitamin B 12(a), something no doctor will need unless he takes up biochemistry. Such seeming absurdities, of course, grow out of uncertainty. As Dean of Medicine Dr. John McCreary, one of Canada’s most respected medical educa-

tors. says, “Some change is vital, but not change for the sake of change: we don’t even know for sure what we’re trying to produce.”

Indeed, the only apparent agreement is that this new-style doctor should have more psychiatric training than his predecessors, and perhaps less training in other fields that have

become the specialists’ preserve. One example: it is often suggested the new GP has no place in the operating theatre, and therefore a lot of the 600 classroom hours most students devote to anatomy should instead be spent learning how to handle the psychological problems of tension and emotional disturbance that are often ere-

ated by our modern, urbanized society.

Despite their failure to agree what the medical schools’ end product should be, medical educators are currently planning how to spend around a billion dollars on health-education in the next 15 years. The federal Health Resources Fund is putting up half the money, and the universities are obliged to raise the other half. And yet so little is known about what these schools should ideally produce that the University of Toronto has just set up a study group to attempt to define a “good” doctor, so it can weed out unsuitable students, and UBC’s Dean McCreary warns, “Since provinces are responsible for their own higher education, there’s a danger we’ll end up producing 10 different levels of quality and condemn the country to interminable mediocrity. In health education there must be some uniformity.”

But the colleges face a more tangible and immediate problem: just to maintain the present doctor-population ratio they must increase their enrolment from 1,266 students last year to more than 1,400 by 1969. The first of four new medical schools was opened last year in Sherbrooke, Que., and the second will open at McMaster University, Hamilton, Ont., in 1969. Two others open in Calgary and St. John’s in the early 1970s. And the new schools, plus the expansion of old ones, generate their own appalling problem: who’s going to teach in them?

There’s already a dangerous shortage of teachers. And since it’s research facilities that attract them, Canada currently has scant hope of ending even the present shortage: we now spend less per capita on medical research than almost any other Western nation, including Portugal, and the talented teachers tend to drift to the U.S., which spends more on research than any other nation. In the past 10 years four of Canada’s medical colleges were either placed on “probation,” or were uncomfortably close to it, by the committee that accredits them as degree-granting institutions because they lacked adequate teaching staff and facilities. “The teacher-supply problem is one of a number that seem to have no solution,” says Dr. A. L. Chute, Dean of Medicine at the University of Toronto.

The western and Maritimes universities have displayed more readiness to join the fight to rehabilitate the GP than the more conservative, specialistoriented schools in Ontario and Quebec. It has, however, been left to the University of Toronto school to set up the most massive curriculum study. At Toronto, Dean of Student Affairs Dr. Jan Steiner, a former GP and subsequently a specialist in pediatrics, is studying both students and graduates to determine just what a “good” doctor really is. In a city where the GP has all but been forced out of the hospitals by specialists, the bias is predictably on the need to produce graduates better equipped for postgraduate training, and Steiner is probably the most articulate spokesman for the left wing of medicine, which believes more, not fewer, specialists are needed to improve medical services.

Steiner argues that before the socalled Knowledge Explosion, medicine

continued on page 100

WHAT'S YOUR DOCTOR’S FIRST NAME? continued

What doctors must learn: they must never stop learning

was more art than science, since doctors could do little for a raft of diseases and organ malfunctions that almost inevitably killed or incapacitated the patient. Now, he says, the scales have tipped the other way, and the new science needs specialists to practise it. “The impact of recently acquired scientific knowledge on

medicine and medical schools is traumatic,” he says. “You have to stop teaching in a vacuum — the student learns about the structure of the brain in one year and it is never related to strokes, which he studies in another year—and at the same time you have to squeeze into six years the training that should take 10.”

Steiner’s solution: “Students must be taught to teach themselves; to realize knowledge is evanescent and that they must never stop renewing their knowledge all their lives.”

The GP rehabilitation effort is, says Steiner, a scandalous waste of time. “What we do now will show up in 10, 20 years’ time. And if it’s wrong,

Canada is in trouble. Today the Canadian public is demanding expertise. If they want a new car muffler, they go to the muffler shop, not the general mechanic. If a woman gets a backache, she wants to see a specialist in orthopedics or a gynecologist, not a GP. Anyone who thinks this trend is likely to be reversed knows nothing about our society.

“We say the public should decide what’s needed. And the public is demonstrating that it wants specialists, experts. Today, no man can know it all, whatever his field, and must practise in a group. But GPs want to make the new doctors over in their own image. The obsession with professional status and the mystical doctorpatient relationship is, in the terms of the world in which today’s students will practise, quite absurd. It’s true we’ll always need people to decide which specialist a patient should see, but whether that person should be a graduate doctor is debatable.”

Group practice of one kind or another is becoming more popular. Everywhere there’s a trend for specialists to gather in one building, if not in a formal group practice. One of the biggest, oldest and most prestigious specialist groups in North America is the Winnipeg Clinic, run by Dr. P. H. T. Thorlakson, one of the elder statesmen of Canadian medicine and himself an “obsolete” general surgeon. He leads more than 50 specialists and sub-specialists, and says, “As a general surgeon there are types of operations I no longer perform because specialists in certain fields — say the neurosurgeon, or the orthopedic surgeon—are more competent.”

Group practice — more time

Group practice among GPs themselves is spreading. Typically, in the St. James suburb of Winnipeg six GPs, all around 40, practise in a clinic and provide a 24-hour, seven-days-a-week service for patients by taking turns at handling emergencies. One of the six says that in three years of solo practice he had one week’s holiday and about a dozen free weekends. In his year with the group this man has had a month’s holiday, a two-week refresher course at university, and he works only one evening in five and one weekend in six. Even so, these GPs—like Thorlakson of the Winnipeg Clinic — regard the home-visit diagnosis as perilous. “Modern medicine demands sophisticated equipment to help with diagnosis, and the patient rarely suffers from being taken to a doctor’s office or hospital where facilities are available,” says Thorlakson.

Probably the only way the more remote communities, most of them either doctorless or short of doctors, will ever get medical services is through group practices or clinics. Doctors are increasingly reluctant to embark on solo practice in remote areas, where they’ll face a spectrum of medical problems undreamed of in medical school. In British Columbia, the college of physicians and surgeons last year set up a three-month cram course to train doctors prepared to go to the hinterland in the sort of emergencies they might expect to face: breech births, logging accidents, minor surgical procedures, and so on. Thus far, no doc-

WHAT’S YOUR DOCTOR’S FIRST NAME? continued

lines are drawn: GPs vs. specialists

In hospitals, battle

tor has applied to take the course.

A clinic or group practice set up in one town and servicing communities around it is the probable solution. And in his exhaustive The General Practitioner, Dr. Chute said that doctors in groups practise better medicine than those working alone because they monitor and stimulate one another.

In this can be seen a trend toward the team approach to medicine which reformers are always talking about, and which often seems to be the onlyone possible when scientific advances demand the use of many skills in one treatment, or operation. A kidney transplant, for instance, involves scores of different medical personnel. Medicine may have become too complex to accommodate the traditional independent entrepreneurial doctor.

The battle lines between GPs and specialists are probably best seen in the nation’s hospitals. In the east, people go to specialists when they need a hospital bed. and this is the cause of much bitterness within the medical profession. Farther west, the GPs still hold sway. In Winnipeg, family doctors currently suspect a conspiracy between specialist and university teachers to exclude the handful of GPs who still have access to the city's hospitals. In Alberta and BC the scales have tipped so that half the staffs of Calgary and Vancouver general hospitals are GPs.

Much of the war of philosophies over medical practice may be caused by the creeping takeover of hospitals by specialists. One student in the Calgary Experiment says he’s taking the GP course, hoping his diploma will help him gain access to hospital beds —and greater income. If a doctor can get his patients into a hospital, he can often make more money. And if this really is a root cause of the GP-specialist battle, then it may also be part of the reason for the hospital-bed shortage. Doctors have a great deal of influence in planning the provision of hospital facilities. Since general hospitals represent the best income, they tend to support general-hospital building programs, when in fact Canada's greatest need is probably for hospitals and homes for the incurably sick, the aged and the convalescent.

Without them, there’s a seemingly chronic shortage of hospital beds everywhere. In Toronto, one doctor says, “People have taken to shopping around the surgeons, seeing which one can get them a bed first. The shortage is critical.” Elsewhere, all hospitals have waiting lists of people needing “elective” surgery — appendectomies, tonsilectomías, hernia operations, cosmetic and corrective surgery. The physical and psychological misery these people suffer by being forced to wait sometimes six months for a bed is immeasurable — and yet Dr. John Crawford, federal Deputy Minister of Health and Welfare, is able to say. “I doubt whether there is a real shortage of active treatment beds in this country.” Kingston, Ont., for instance, has plenty of general-hospital beds. But there’s only one hospital for incurables and space must be found for them in the general hospitals.

Some doctors say universal hospital insurance is partly responsible for the bed shortage. Patients stay in hospital longer than necessary because it's free, and restful—and so in the past three years most of the country’s hospitals have set up policing committees to determine whether doctors are abusing the facilities either by admitting pa-

tients who could he treated as out-patients. or by permitting them to stay longer than needed. And Saskatchewan. the home of socialized medicine in North America, is reportedly planning to charge a daily fee to make sure patients will leave as soon as possible.

But once you’re in hospital, is it a

good place to be sick? Of course, it’s better than the back bedroom at home. But there is evidence to suggest our hospitals could all be improved, and the smaller ones may be positively unhealthy.

Dr. William Iveson Taylor, secretary of the council set up by medical and hospital associations to establish minimum hospital standards, says most hospitals need better intensive-care facilities, and the bigger teaching hospitals, particularly, need to “improve

WHAT’S YOUR DOCTOR’S FIRST NAME? continued

New hospitals sometimes are only town status symbols

communications" between specialty departments. Patients suffer from this lack of communication. When a young actor was hurt in a car crash in Alberta, his life was saved by the teamwork of a neurosurgeon, an orthopedic surgeon and an internist. But as he mended these men lost interest beyond determining that in their

particular areas of specialty he was making satisfactory progress. Since none of them could tell him about the other's work, some of the questions that mattered most to him—“When can I go home? Will I suffer any aftereffects?" — went unanswered. His family called in a GP, who later said. “By the time 1 arrived the boy needed

another specialist—a psychiatrist for his anxiety problems.”

There is a trend in bigger hospitals to set up departments of general practice. so that GPs can maintain contact with their patients now in specialists’ hands. “It's an encouraging sign, but it's moving slowly,” says Dr. Taylor.

Staffing problems bedevil most hos-

pitals. Nurses, loaded with work that could be done better by housemaids, commonly complain they can provide barely adequate care—and they can't all be wrong. This, say nurses’ organizations, is one reason why they flood south to the U.S. where pay and conditions are better.

More alarming is the fact that many hospitals spend millions of dollars on sophisticated equipment and facilities mostly to keep up with the Joneses in the hospital business. Some measure of control can be, and sometimes is, exercised by government agencies which provide the cash, but too often money is allocated on the basis of demand and local pressure, not on need. Regional control of hospitals and their facilities may be the logical solution, but hospitals and their influential boards usually resist it strongly.

In BC, for instance, government surveys showed one big cancer-treatment centre located in Vancouver could best deal with the province's needs. But New Westminster's Royal Columbian hospital wanted its own radiology treatment unit. Because it claimed this would duplicate the facilities in Vancouver, 12 miles away, the government refused aid. But the hospital raised the cash privately and, says one deputy health minister, “provided facilities for which there's no real need.”

Small towns often build or retain hospitals that are more valuable as status symbols than treatment centres, since more sophisticated hospitals are near enough to handle local needs. There's a classic case near the Bruce Peninsula area of Ontario. Walkerton (pop.: 4,152) has a 104-bed hospital, and is expanding it. Hanover (pop.: 4,830) five miles away has a 59-bcd hospital, and is expanding it. Chesley (pop.: 1,697) 10 miles north of Hanover also has a hospital with 23 beds. And Durham (pop.: 2,425) 10 miles to the east of Hanover has a 32-bed hospital. Each of them duplicates facilities provided by the other.

Many of these small hospitals do not meet the standards set by Dr. Taylor’s accrediting council. While all the hospitals with 300 beds or more meet the standards, only 70 of the 337 hospitals with between 25 and 100 beds have been accredited.

Often, hospitals obtain equipment but haven't staff competent to use it. Dr. Bernard Brosseau, Executive-Director of the Canadian Hospital Association, says, “Things like cardiovascular treatment centres for open-heart surgery and radiological units cost millions, yet small hospitals install them when, good God, they often hardly even know how to use them.” And Dr. Taylor says that small hospitals almost always want surgical facilities, when they often lack facilities to give adequate preand post-operative care.

Tighter, more centralized control would solve many of these problems, as it would many of the other ills that beset the world of medicine. But Medicare planned for 1968 won't provide it—and, indeed, state control can create as many problems as it solves. Arid yet there is so little agreement among doctors, hospitals and nurses that they seem incapable of curing themselves. Until they do, they'll be less competent to cure us, the patients. ★