Medicine

Doctors in crisis

Susan Riley September 29 1980
Medicine

Doctors in crisis

Susan Riley September 29 1980

Doctors in crisis

Medicine

Susan Riley

A hundred years ago doctors were regarded as savants rather than technicians. Whatever the reality, a comforting image grew up: the doctor as wise, fatherly compassionate healer. He—and it was inevitably a he—would arrive at your house in the middle of the night, toting a black bag full of bottles and tubes. Along with time-honored medicines and gentle reassurance, he brought an air of rumpled serenity to the panic of the sickroom. And—as he bandaged the wound or helped the fever abate—he would discourse knowledgeably on the political and literary currents of the time. Above all, he was someone you could trust.

But nowadays that image is changing, and changing fast. Doctors today are as likely to be seen as hard-drinking money-grubbers with inflexibly conservative social attitudes and low golf handicaps. They no longer visit you; you visit them—even if it means taking a number and waiting in line like a customer in a butcher’s shop. Besides that, they often seem to care more about their own financial health than your piffling illness. Next week, for instance, federal and provincial health ministers will meet in Winnipeg to discuss improvements to medicare; on the other hand,doctors in Vancouver last week for the annual convention of the Canadian Medical Association were clamoring about the latest threat to their livelihood—the recommendation by the recent Hall report on medicare that extra billing be banned. Never mind that the debate is as much about declining power as it is about declining incomes, that what doctors are facing is a profession in crisis—the public generally sees only one thing: some of society’s richest citizens (at a net average income of $50,500 a year) screaming for more. Stung by studies such as the one done for the Hall report showing a strong decline in public trust, and fearful of even more government interference, doctors are having a hard time proving their worth.

Their case isn’t helped much either by the persistent “horror stories.” An Ottawa doctor recently pleaded guilty to charges of sexually molesting a patient—not an unusual case in itself. What was more damaging was the fact

that the Ontario College of Physicians and Surgeons—which supposedly polices its own members—had dismissed similar complaints against the same man. In Toronto recently, a heavily sedated patient was refused an abortion at the last minute when her anesthetist discovered she hadn’t paid two previous bills. “I’m not a bloodhound,” explained Dr. Willard Wilson, “but this patient had to be punished.” Again more aston-

ishing was the subsequent admission of the Ontario College that later this month it will be investigating two more complaints against doctors who demanded payment before operating. Last year, 53-year-old Frank Russell of Happy Valley, Labrador,was diagnosed by his doctor as suffering from gas pains. When the pains didn’t go away Russell flew to nearby Newfoundland where surgeons removed a malignant 10-pound tumor from his stomach. To add insult to injury, when the people of Happy Valley started complaining about the generally poor quality of medical care in the tiny community, the Newfoundland Medical Association

warned them to stop criticizing, or they would lose what little service they had. No wonder malpractice suits in Canada have quadrupled over the past decade — from 80 to 343.

Meanwhile,the Alberta Medical Association (AMA) recently was forced to circulate a “danger list” of violent patients after two doctors were murdered in their offices and a third badly stabbed. This can’t be construed as the cut-

ting edge of a public backlash since the attacks were the work of “paranoid and delusional individuals,” but as the AMA’s Dr. Robert Clark says, the attacks may have been sparked by the physician’s traditional image of omnipotence which sets him up as the perfect target.

Less spectacular, but equally damaging to the old image of the friendly, selfless family doctor,are the other “doctor stories”: statistics and studies showing that high living, drug abuse and alcoholism take their toll in the healing profession, as in others; the enshrinement of workaholism as a noble tradition; and the fact that, in 1979, while Canadians were shelling out for their education, more than one-third of Canada’s

graduating class—605 doctors—left this country for the fatter paycheques and allegedly greater “professional freedom” south of the border. “Most young students come to med school with the notion of service, but somewhere along the way it gets perverted,” says Dr. Sidney Lee of McGill University in Mon -treal.“Some of them think they should be paid like baseball players.”

In fairness to doctors, in the ’70s their earning powers did decline in relation to other professions, but there are signs that the trend has been arrested and incomes are on the rise again—at least in Ontario. And most people would probably react the same way 81-year-old Emmett Hall did recently when asked about the narrowing gap between doctors’ salaries and those of blue-collar workers. Said the father of medicare, and author of the latest review: “I can’t see anything wrong with that [the narrowing gap], because increases in the cost of living bear most heavily on the

low-income brackets.” In other words, doctors won’t starve.

It’s hardly surprising that as public criticism mounts and the patina of omniscience wears thin, doctors, like businessmen during the flower-power ’60s, are feeling beleaguered and misunderstood. Ever since medicare was introduced for the first time in Saskatchewan in 1962 and doctors retaliated by going on strike, there has been an uneasy partnership between the profession and the “system.” With Hall proposing even more restrictions on the right to charge for services, the medical establishment has responded with a chippy defensiveness. Dr. Alex Mandeville of the British Columbia Medical Association denounced the Hall report as “socialist,” while Dr. Robert MacMillan, head of the Ontario Medical Association (OMA), warned doctors will consider going on strike if they are forced to remain within medicare. “We’re like

wild stallions who wander into a stall,” he once said. “The minute someone closes the door behind us we go wild.” Underlying all the talk of money is the real worry—a loss of status within the health system which the OMA’s Dr. Ed Moran says is “de-professionalizing” doctors. That fear is reflected in medical schools and hospitals, where confusion reigns. “Doctor-bashing is a popular sport,” says University of British Columbia med resident Bryan Barootes, “and interns bear the brunt of it.” However bad the new image, there remains across the country the many individual doctors who don’t deserve the criticism: who still hold their patients’ hands through operations; who make house calls—an average of eight a week among GPs in the Halifax area— and who combine old-style Victorian manners with Jetstar technology. And there is a minority of reformers within the profession who welcome the flack being hurled at their group. “It’s high

time doctors were asked to explain themselves,” says Dr. Michael Rachlis, an energetic 28-year-old who works at Toronto’s experimental South Riverdale Community Health Centre. “We’re not gods, and we should stop acting as if we are.” Another new wave doctor, 30year-old Greg Blaney of Ottawa, says medical schools should stop dispensing elitist notions along with the diplomas. “From the minute you start you’re told you’re special, worth more than other people, and you’re told subtly that people are totally ignorant and you’re supposed to rescue them when they’re sick.”

And the patient who is sick, or worried, or afraid isn’t at his most assertive—even if he speaks the language of the middle class. “Our deepest paranoia

is our health,” says federal Health and Welfare Minister Monique Bégin, and she draws her observation not just from Gallup polls but from personal observation. A former heavy smoking habit and other medical problems have landed her in hospital twice in the past 10 years. “You can be a forceful individual in the outside world,” she says, “but when you’re in one of those incredible gowns they give you in hospital you feel very ordinary.”

However, the current crisis of confidence in the medical profession may not be merely a question of the attitudes of doctors and patients to each other. Both are victims of a seemingly archaic system of payment that produces “assembly line medicine”—the fee schedule. Under this system most doctors—except those on salary at clinics or hospitals—are paid by government on a piecework basis, like workers in a shoe factory. The rates vary from province to province (see box page 48) but what counts is

quantity rather than quality. Almost everyone recognizes the shortcomings of the fee schedule, but no one has so far come up with a better idea. Hall says it is impractical to put all doctors on salary, particularly the thousands who work independently in small towns. Others have violent philosophical objections to becoming civil servants—particularly in Alberta, where the notion of doctor-as-small-businessman is entrenched. Some provinces, like Ontario, have tried to make the fee schedule more flexible, but doctors still get $8 to treat a sore throat, which might take five minutes, and only $20 for a full half-hour of counselling for someone who is depressed, for instance, or abusing his health with bad habits.

This discrepancy in the fee schedule has become particularly important now that so much of the illness a family doctor sees stems from stress caused by poor lifestyle and difficult work and

home situations—not problems cured by the usual five-minute chat, two aspirins and plenty of fluids. In fact, the fee schedule stems from a notion of the doctor as a curer of sickness rather than a promoter of wellness. “Only two per cent of Ontario’s health budget goes into public health,” laments Susan Berlin, a Toronto municipal health planner and one of the authors of a bench-mark study entitled Public Health in the 1980s. She blames it partly

on the inordinate political power wielded by doctors who are not anxious to surrender their turf to nurse practitioners, nutritionists, psychologists, therapists, feminist counsellors, public health specialists—or any of the other professionals concerned with the broader aspects of health.

An interdisciplinary approach to medicine called “holistic”—that is the treatment of the whole person, even the whole family, rather than a specific ail-

ment—has in fact become a rallying cry for the reformist wave within the profession. It aims to treat the broken mind, the broken spirit, even the broken heart, as much as the broken body—in short, to deal with emotional problems before they turn into heart attacks, ulcers or cancer. Trevor Hancock, outspoken doctor with Toronto’s public health planning unit, says medical schools still take too technological an approach. “We should also be taught meditation,

the spiritual and psychic aspects of healing.” There are indications that this approach is taking hold, at least in some of the country’s more progressive medical schools. Dr. Carl Moore, chairman of the family practice department at Hamilton’s McMaster University, says students there are taught to look at a patient “as someone with a problem, rather than someone with a disease.” And at the University of British Columbia, Dr. Al Boggie, a tweedy Marcus Welby-type, often tells his students “to look behind the fridge to see how many bottles there are; it really helps a doctor to see how patients live at home.” Medicine will also become increasingly humanized as medical schools

open their doors to a wider sampling of people, rather than relying exclusively on brainy science grads more familiar with geometric stress than the human variety. Already applicants to McMaster are required to submit autobiographical letters outlining their goals and values along with their marks transcript. And as more women become doctors (in Ontario alone,40 per centof students in family medicine are women), their arrival in the profession could help to speed up the breakdown in the traditional male-female, boss-slave, doctor-nurse relationship. In fact, a democratic “team approach”—where different professionals interact across the boundaries of sex and education—is central to holistic medicine. That urge to “demystify” the physician’s role is what has the OMA’s Dr. Moran worried when he speaks about doctors becoming “merely another resource.” But many doctors say there will always be a need for their special skills. As McMaster’s Dr. Moore puts it: “There really isn’t much danger of us becoming glorified social workers.”

But despite changing attitudes, there are still doctors practising who are too rushed, too old, or too out of touch to give good care. There is the high-powered woman executive in Victoria, B.C.,

who is told by her aging family doctor that the eczema on her hands is the result of having them in dishwater too much—hardly her natural habitat. More seriously, there is the well-chronicled over-prescription of Valium and other drugs to mask the physical symptoms of emotional distress. And many doctors are hardly equipped to counsel anyone about emotional problems or lifestyle-related diseases—especially when their own life habits would look far from healthy under a microscope. Recent studies show that alcoholism is a serious problem for doctors and drug addiction rates are notably higher than for other professions. Several provincial medical associations are now conducting studies on the alcohol problems of their own doctors and the Ontario College of Physicians and Surgeons has even set up a counselling service “for doctors on chemicals” which receives at least five calls a week.

But the most stubborn epidemic of all—and perhaps the root cause of other ills—is workaholism. Says Dr. Melville

Revenue Canada’s 1979 Taxation Statistics

Average Annual Income—1977

Physicians & Surgeons 50,500

Dentists 42,600

Lawyers 41,400

Accountants 33,700

Engineers & Architects 33,000

Teachers & Professors 17,600

Federal employees 15,000

Miscellaneous professionals 14,600 (nurses, vets, etc.)

Salesmen 11,700

Farmers 10,000

Fishermen 9,900

Pensioners 5,000

Vincentof the Homewood Sanatarium,a private psychiatric hospital in Guelph, Ont., many of whose patients are doctors: “So many physicians feel they mustn’t take time off, they mustn’t be sick, they mustn’t take a holiday, and that ethic pushes them to discomfort. Then they try to treat the discomfort with drugs.” Vincent tries to warn med students of the dangers of workaholism in guest lectures at medical schools, but it is sometimes an uphill battle. “Very often the students’ role models—the successful private practitioner, or the best professors — are workaholics themselves.”

Nonetheless, there are signs of rebellion in the ranks. In April, 800 residents and interns at hospitals in Quebec went on strike for five weeks to press demands for better working conditions and salaries. And in June, hospital interns and residents in five Ontario cities—some of whom work up to 90 hours a week at an average annual salary of $14,000—staged a two-day workto-rule in a contract dispute with the provincial government. It is ironic that doctors who are so handsomely compensated by society later in life are expected to endure what, in the words of one, is a “trial by fire” as interns and residents. Even so, the strike tool is one most doctors are reluctant to use because of what they see as their sacred duty to serve. In the same way, doctors feel guilty about leaving work at a decent hour because they know there will always be someone else on the phone wanting help. Is it a simple question of a shortage of doctors? That may be the problem in some individual communities, but a recent study by the federal government says Canada actually produces a surplus of up to 400 doctors a year.

Still, there are lineups at emergency wards across the country and what patient hasn’t spent more than an hour in a crowded waiting room only to be whisked past the busy doctor’s stethoscope in less than a heartbeat? How can

this unhappy cycle be broken? Some medical reformers pin a great deal of hope on community clinics—pioneered in Saskatchewan, birthplace of medicare, in widespread use in Quebec and, as usual, being approached with wary suspicion in Ontario. In Quebec, where there are 92 such clinics flourishing, a shaky start in the early ’70s— marked by disorganization and abstruse debates about whether leftist politics should be dispensed along with prescriptions—nearly scuttled the

whole idea. “The polemics are gone,” says Christos Sirros, director of Montreal’s Park Extension clinic. “When a guy has a bedridden mother he doesn’t want to hear a Marxist-Leninist explanation of how the bourgeois capitalist put her there. He wants her placed.” And while the clinics are still underused, an important 1978 study by four young sociology students from Montreal, showed health care dispensed at the community clinics was “significantly better” than the traditional health care system. For one thing, doctors are on salary (in the $33,000 to $38,000 range) and average a leisurely half-hour per patient. The study also showed clinic doctors generally treat their patients with respect—making them participants in treatment rather than recipients.

But none of that is much comfort to

the poor, to native people, to those living in remote communities where medical care is either spotty or simply unavailable. They will continue to be ignored as long as governments deem them numerically insignificant.

On the other hand doctors, 33,000 of them in the country, still wield a power and influence far greater than their number—despite the public moaning from their official spokesmen and despite growing public skepticism. But there are signs that their power is eroding and will continue to erode unless they find spokesmen who can communi-

cate their concern for health as well as for wealth. It is painfully evident—as the current medicare debate shows— that years of technical training and overwork have left most doctors illequipped to handle even the most basic public relations: making their own case, politically and publicly. Many modern doctors could tell their rumpled Victorian predecessor a thing or two about medicine. He, on the other hand, could probably tell them a thing or two about people.

Anne Beirne

Mark Budgen

June Rogers

Dale Eisler