Small-town family doctors diagnose the health system’s ails
Drs. Gordon Brock,Vydas GurekasFebruary142000
The view from the trenches
Small-town family doctors diagnose the health system’s ails
Recent stresses on emergency departments across the country have shown up most dramatically in big-city hospitals, where rerouted ambulances and delays in admitting patients have captured the publics attention. But the problems behind the periodic crises in emerg are systemic, affecting all aspects of the health-care system.
Two family physicians in the western Quebec pulp-and-paper town ofTémiscaming offer what they call “the voice of the disenfranchised, powerless and increasingly alienated and burned-out frontline workers. ”
Drs. Gordon Brock
We hope that Maclean's perceptive and accurate series of articles on the problems involving medicare will be successful in informing the public at large of what we in the trenches of medicine already know: Canadians are the possessors—and the victims—of an increasingly mediocre and outdated, out-of-step system of health care. Canadians are right to question why an $80-billion system can collapse under the weight of something as predictable as the winter flu epidemic.
Media reports prominently feature bureaucrats, health-care “experts”— often self-styled—and workers in university-type tertiary-care hospitals. Their statements so often exhibit those three Canadian staples: whining, blaming faceless “government cutbacks,” and pleas for “more funding” for their particular constituency. Often lacking in the debate has been the voice of the frontline workers, who have seen a once-proud system deteriorate into mediocrity.
We are two family physicians with almost 50 years’ experience between us of work in an underserviced and overstressed rural environment. With two or three other physicians, we are responsible for the 24-hour care of 5,000 people. Through proverbial thick and thin—flu epidemics, multiple-vehicle car accidents and the like—we are able to hang a sign outside our small emer-
gency department: “We never close. We never refuse a patient. We never turn away an ambulance.” Contrast that to recent cases in the Toronto area of two patients dying after being refused access to the nearest hospital, with infinitely more resources than we have.
Medicare was conceived in 1962. Since then, society has seen many changes, some predictable at that time, others perhaps less so. A few of those changes:
• Aging of our society. Older people require more medical resources than younger people. It’s as simple as that.
• Medical technology: Thirty-eight years ago, the system did not have to pay for CAT scans, cardiac surgery on people in their 70s, or expensive and complicated chemotherapy treatments for cancer patients. These technologies and abilities just did not exist.
• What we call the McDonaldization of medical care. People today demand convenience, 24-hour service and prompt “cures.” The emergency room has, for increasing numbers of Canadians, become the family physician: emergency rooms that were conceived to handle heart attacks, car accidents and strokes are now congested with flus, colds, aches and pains, problems that in another era were handled by the family physician, grandparents or just waiting a day or two until they passed.
Our system now resembles an out-
of-shape 40-year-old trying to run the marathons that seemed so effortless 25 years ago. Along with many other frontline workers, we believe we have some sensible and workable ideas to update the system.
Our health-care administrators need to return to the ABCs: They must address Accountability, cut back the Bureaucracy and encourage Creative solutions:
1. We believe that the traditional model of the solo family physician working alone out of a 9-to-5 office is obsolescent. Too many family physicians leave only an answering-machine message after 5 p.m.: “The office is closed until tomorrow morning. If you have an emergency problem, please go to your nearest emergency room.” It is easy to get angry at patients arriving in emergency rooms at all hours with minor problems, but often there is legitimately no other place for them to turn to. Physicians must be held accountable for the entire health-care needs of their practices and given the resources and incentives to care for their patients 24 hours a day.
2. As many a patient has found, our current “fee-for-service” medicare system encourages assembly-line techniques: get that patient in and out of the office as quickly as possible, shuffle as many through as you can per hour. We find it hard to believe that a better pay-
ment system cannot be put in place that recognizes the new realities, a system that will compensate physicians for telephone advice and reward those who, say, vaccinate a large proportion of their elderly patients against influenza.
3. Hospitals must be prohibited by law from closing their emergency rooms, especially to ambulances, when they are “overloaded.” Hospitals have disaster plans for handling things like bus accidents. Why not require them to have disaster plans for handling emergency congestion during the flu season?
4. University and big-city emergency rooms that were conceived to handle acute emergencies must get out of the business of treating flus, sore throats and minor pains. Resources and incen-
tives must be given to set up “24/7” outpatient acute-care facilities to see those patients quickly and efficiendy 24 hours a day, seven days a weeks in a more patient-friendly mode than most hospital emergency rooms we have seen. As is already the case in Quebec, new family physicians setting up in urban areas should be required to devote a certain number of hours per month working in these facilities as a condition for billing medicare.
5. Waiting periods in hospital emergency rooms must be cut down. Lab and X-ray tests on those patients must be done on a priority basis, and specialist physicians called to evaluate emergency-room patients must see those patients prompdy, not, as is often the
case, after delays of several hours.
6. Imaginative solutions need to be found for the winter emergency room crunch—not just the same tired solutions trotted out every year. For instance, why can’t a group of hospitals in an urban area pool resources to set up an emergency department SWAT-like team of nurses and physicians who can rush from hospital to hospital to relieve local congestion?
7. Finally, we do not believe that major reforms are possible until the public demands accountability from those in charge, be they politicians or the chief administrators of hospitals. Because of the Canadian public’s reputation for tolerating mediocrity, we are not holding our breath on that one. ES]
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