SPECIAL REPORT

FEVERISH relations

The traditional doctor-patient relationship is breaking down as a result of government cutbacks and patients demanding to be treated as customers

MICHAEL POSNER November 13 1995
SPECIAL REPORT

FEVERISH relations

The traditional doctor-patient relationship is breaking down as a result of government cutbacks and patients demanding to be treated as customers

MICHAEL POSNER November 13 1995

FEVERISH relations

SPECIAL REPORT

The traditional doctor-patient relationship is breaking down as a result of government cutbacks and patients demanding to be treated as customers

suffering from a heavy cold and a very sore throat one day last year, Vancouver software developer Bruce Hickey decided to visit a local walk-in clinic. Inside, he happened to glance at

the patient manifest. To his astonishment, he noticed that he had been allotted just six minutes to spend with the attending physician. When he was ushered in, the doctor raced through his examination and diagnosis, even before Hickey felt he could fully describe his symptoms or his concerns. Recalls Hickey, 28: “It was like, here’s what you have, here’s your sheet, here’s your prescription and here’s the door—you’re gone.” Hickey’s experience is hardly unique. Indeed, according to the new Maclean’s /Medical Post/Angus Reid survey, almost four out of 10 Canadians are unhappy with the amount of time their doctors spend with them. An even larger number (56 per cent) are frustrated by the length of time they routinely spend in the waiting room. Says Connie Sydorchuk, 35, an engineering technologist in Calgary: “You go in there, you’ve left work, you’re sitting for an hour. I think you should be able to bill them for your time.”

As the Maclean’s poll shows, temperatures are

plainly rising in the doctor’s waiting room. As public purse strings draw ever tighter, both physicians and patients seem increasingly dissatisfied—doctors with their income and their perceived inability to deliver the highest quality of medicine; patients with their access to the system. As a result, the traditional relationship is starting to fray. “Patients are now customers,” says Angus Reid vice-president Andrew Grenville.

“They don’t have the same deference they once did.

They no longer see their doctors as holy healers.”

And the doctors are on the defensive. “They don’t have the same ability to command resources,” adds Grenville. “They’re frustrated because they know they can’t do things they should be able to do.”

When it comes to office visits, Canadians also have some pretty firm ideas about why they’re being forced to wait: nearly two-thirds of those surveyed believe that doctors are maintaining their own income levels by encouraging patients to come for more visits than are strictly necessary. “The fee-for-service system encourages that practice,” says John Ronson, CEO of Quantum Solutions, a Toronto-based health-care consulting firm. “It’s revolving-door medicine, and it makes the level of quality worse.” Dr. Alan Katz, professor of medicine at the University of Manitoba in Winnipeg, adds bluntly: “Nobody seeing 60 patients a day can provide quality health care.”

Surprisingly, fully seven out of 10 doctors agree that some of their colleagues are maintaining their incomes by seeing patients when it is not strictly necessary. But almost four out of 10 defend the practice as “the only reasonable response to our ever-shrinking payment schedule.” And those who have not succumbed to that temptation pay a price. “I only see what I have to see,” insists Dr. Louise Cloutier, a general practitioner in Dartmouth, N.S. “And I only do what’s required in terms of follow-up. But my fees have been reduced 23 per cent over the past six years, and my costs for overhead and staff have not been cut. The fees get cut, but

the mortgage payments stay the same.” When asked about the doctors’ widespread belief that their profession is seeing patients only to maintain income levels,

officials at the Canadian Medical Association declined to comment.

Inevitably, professional morale suffers. “I’ve never seen it as low as it is today, says Dr. Robert Wedel, who works in an eight-doctor family practice clinic in Taber, Alta. “And it’s not just the dollars being taken out of the system. It’s the uncertainty about what’s coming next, the lack of clarity about government intentions.”

Increasingly, it seems, the Canadian medical community sees itself as unloved. “It’s a feeling of not being appreciated,” says Dr. Ed Brown, an emergency physician at Peel Memorial Hospital in Brampton, Ont. “It’s going out of the way to do your best and not feeling anybody cares about you. It’s reflected in the media, and

in the salary cuts by government. Quite literally, your services are not as valued.” Indeed, the doctors’ poll shows that almost one in four physicians is now dissatisfied with their profession, compared with only one out of 10 in 1992.

“Don’t get me wrong,” says Dr. David Cram, a general practitioner in Souris, Man. “I love the people and the rural life. But I earn $15.65 per office visit. Now take 40 per cent off for expenses—rent, secretary, heat and equipment. Then, I pay the government 50 per cent of what’s left. I’m telling you, it’s not the big bonanza people think it is.” On an hourly basis, says Dr. Marlene Spruyt, president of the Ontario College of Family Physicians, members of her association “are not paid significantly more than secondary school teachers with a master’s degree.”

Although the Maclean’s survey demonstrates that three out of four Canadians (78 per cent) think the amount of money practitioners now earn is fair, only 54 percent of doctors agree they are adequately compensated. One much-debated solution to the compensation dispute is putting the country’s doctors on salary. Calgary’s Sydorchuk, for one, thinks “that might be a better way to go.” And

many other physicians agree. Six out of 10 doctors surveyed said they would be willing to see their net income reduced in exchange for a salaried position with a reasonable pension plan and other benefits.

Yet, while acknowledging that some physicians are guilty of abusing the fee-for-service system, many observers—doctors and patients alike—think there is culpability on both sides of the examination table. “It’s rampant consumerism,” says family physician Dr. Mark Doidge, who runs a clinic in east-end Toronto. “There is a massive sense of entitlement The patient comes in saying, ‘ This is what I want.’ And the doctor, afraid to say no, afraid of formal complaints being lodged, mostly capitulates.”

Were it not for the current revenue pressures, doctors might have more time to brief their patients and explain why, for example, complete batteries of neurological ! tests are not required for every tension headache. But z as Dr. Alan Katz notes: “If you’re seeing 60 patients a p day, you can’t take the time to educate them about these things. So you opt for the quick fix.”

And that, says Eric Lewis, a former Toronto Transit Commission driver now living on a disability allowance in Curtis, Ont., outside Toronto, is precisely what many patients demand. “The consumer isn’t satisfied unless he walks out with a prescription in his hand,” says Lewis, whose brain stem was sheared in a car accident seven years ago and who has spent hundreds of hours since then in doctors’ offices. ‘Without a prescription, he doesn’t feel serviced. And if he isn’t treated that way, if he doesn’t get it, he will go elsewhere. The doctor, of course, wants to keep him happy, so he gives him the drug.”

Still, as the Maclean’s survey shows, most Canadians continue to express remarkably high levels of satisfaction with their physicians—from the way in which they get their medical questions answered (68 per cent), to the level of concern shown (68 per cent), to the amount of time spent dealing with their problems (61 per cent). Moreover, seven out of 10 of those polled think physicians are well informed, are not too quick to write prescriptions, and generally treat them, in the words of the poll’s questionnaire, without arrogance or insensitivity. Only one out of four say they have experienced delays due to cutbacks in the system.

“I have been lucky enough to deal with excellent general practi-

tioners and specialists I have had complete faith in,” says Cathie Watkins, 34, a high-school home economics teacher in Coquitlam, B.C. She had the same family physician for 25 years and, when he retired, the new general practitioner spent extra time familiarizing himself with her medical history. Waiting, she concedes, can sometimes be a problem, but Watkins does not blame her doctor. “It’s the patient who comes in for an earache and then insists on having his sore back, his hacking cough and skin rash looked at as well,” she says. “People have to be more realistic about why they’re seeing their doctor. You can’t go every time you break a fingernail.”

Not surprisingly, perhaps, when doctors become patients, their evaluations of the service they receive is even more positive than that of ordinary Canadians. Only 15 per cent of the doctor-patients say that their physician has behaved arrogantly or insensitively—compared with the 31 per cent of the public that reports such treatment. And while only five per cent of the doctors surveyed think practitioners are too quick with the prescription pad, more than one in four (27 per cent) regular patients holds that view.

“MDs are serviced by the drug industry,” says Lorna Hancock, executive director of the B.C.-based Health Action Network Society, a nonprofit educational charity that researches “complementary medicine.” “That’s their range of weaponry. They don’t consider alternatives. For some reason, they develop this attitude that scientific methodology is the only thing credible, and anybody with another opinion has got to be crazy or undereducated.”

Even many doctors think the profession’s reliance on drugs, especially expensive drugs, is unnecessary. “There are lots of cheaper, so-called orphan drugs around, says Dr. Brown, who is also an associate of Sunnybrook Hospital’s Institute for Clinical Evaluative Sciences in Toronto. “But nobody really markets them. For example, Cimetidine, which is used for ulcers, is an inexpensive and very effective drug.” But most doctors, Brown says, instead prescribe the more expensive, best-selling Zantac.”

In fact, despite the generally favorable rating physicians receive, nearly four out of 10 Canadians (38 per cent) have been irritated enough to switch doctors. The principal ground for switching: being treated arrogantly or insensitively. “I guess I’ve just had bad luck with doctors,” laughs Ken Doucette, 68, a retired farmer living in Dysart, Sask.

“One guy told me I’d had an ulcer attack when I had gallstones. Another doctor told me I had cataracts, which I didn’t. And another told me I needed to have spinal fusion carried out, and said I’d be on my back for three months. Fortunately, I got a second opinion, and was out of the hospital in eight days.”

Others agree that the profession seems to breed arrogance, but say that finding sympathetic doctors is not difficult. “When I was younger,” says Vancouverite Hickey, “I held them in some sort of awe. I would listen to what they told me and just do it. Now, I question what they say, based on the knowledge I have. It’s the same as questioning your mechanic or stereo repair guy.” Among physicians, there is some ambivalence about treating patients armed with an attitude. On the one hand, two out of three say they would rather deal with a patient who is semi-informed than one who relies solely on them. On the other, about one-

Many patients want their

doctors to spend more time seeing them

half think it is harder to treat patients

who have done some reading on a condition than it is to treat those who have read nothing.

Gender plays a part in the findings, with women tending to experience more problems with their doctors than male patients do. More than one-third (37 per cent) cite incidents of arrogance or insensitivity, compared with just one out of four men. And six per cent say they have been sexually harassed by physicians; no males reported having encountered such abuse. Doctors, however, frequently mention a different form of harassment: more than three-quarters (77 per cent) claim they have been verbally assaulted by patients or their relatives.

The doctor-patient relationship, of course, lies at the very core of attitudes about the health-care system. And its erosion, many observers suggest, is part of a deeper current, one that is restructuring vast stretches of the broader landscape. Pollster Grenville, for one, regards it as “yet another tear in the social fabric,” one that may well get worse before it can get better.

MICHAEL POSNER