Essay

A DOCTOR'S ANGRY DIARY

Making the local rounds in Canada’s crumbling health care system

DR. STEPHEN KALADEEN August 19 2002
Essay

A DOCTOR'S ANGRY DIARY

Making the local rounds in Canada’s crumbling health care system

DR. STEPHEN KALADEEN August 19 2002

A DOCTOR'S ANGRY DIARY

Making the local rounds in Canada’s crumbling health care system

Essay

DR. STEPHEN KALADEEN

OVER THE PAST decade, the landscape of Canadian health care has changed remarkably. Most people would probably say the changes have weakened the system and that they do not enjoy the services they once did. As a doctor, I have seen this quiet tragedy unfold first-hand. Crises sparked by funding cuts and reorganizations have occurred so frequently that health care providers have virtually forgotten what it was like when we had stability and growth in our industry. While our political and intellectual elite debates endlessly how to integrate health care “systems” to bring “seamless” care to our population, the actual system for providing the care has slowly disintegrated.

As a result, both citizens and health professionals have lost confidence in a system that was once a model for industrialized nations. The pride my Guyanese immigrant family felt when I graduated from medical school has given way to suggestions that perhaps I should move to the United States, “where they treat doctors better.” How we as a nation have arrived at this state can be chronicled by a review of the many policy changes enacted by our various government bodies. But it may best be seen through the eyes of someone dealing daily with people the system was designed to help. Here is my diary of a typical week in my town of Trenton, Ont.:

Monday; My day begins with a trip to the hospital. I was on call last night and have to do rounds on the newly admitted patients. The first is an elderly woman diagnosed with leukemia, a cancer of the blood cells. This woman has recently had chemotherapy that has all but wiped out her ability to cope with infection. She developed a fever during the night and came to the hospital. Her fever is a strong sign she will develop a life-threatening infection. When I enter the room, a sad

woman meets my gaze. She looks exhausted from the chemotherapy and is bravely attempting to maintain her dignity and composure. Pale and drawn, she attempts to straighten out the turban covering her now bald head. “Good morning, doctor,” she says. “How are you?” I reply, slipping on my professional mask. “I am Dr. Kaladeen and I have been assigned to look after you—I guess you don’t have a family doctor?” No, she replies: “He left town several years ago and I haven’t been able to find a new one since then.”

The woman and her husband are elderly farmers. I come to realize that this woman has been desperately afraid for herself, but also for her elderly husband, who had difficulty visiting the hospital. I leave the room feeling that she probably needs to stay in hospital for a few days. But she also needs a friend whose judgment and experience she can trust. That should have been her family doctor. Reluctantly, I have been forced into the job.

Clearing through my assortment of patients, I wink at the nurses who have become good friends over the past 10 years. They are scrambling to discharge people to make room for new admissions waiting for a bed in the emergency room. We used to have more help getting patients ready for discharge, but this job has fallen on the nurses’ already overworked shoulders. We have very few fulltime nurses now—most of the younger ones, unable to get full-time employment in Canada, have left for the United States. Those who are here often have to juggle two part-time jobs to make ends meet. Recently I met a nurse I used to work with. She quit her job at the hospital and was now working at a car dealership. She explained that she was much happier with her job as it was so much less stressful. Tuesday: The hospital lounge with free coffee beckons. Years ago, in happier times, the staff doctors used to hang out

there sipping coffee and trading war stories; now, it is getting more and more quiet. During the past 10 years we have lost so many doctors that, at 39,1 have inadvertently become one of the youngest docs here.

Much complaining takes place among the medical staff—especially the old curmudgeons who bemoan the “good old days.” I often feel like saying, “Hey, guys, I haven’t even had any good old days.” Many are considering retiring, but the Nortel/tech-stock meltdown has quashed their plans. Some of these guys have kids my age. I notice that many of these docs are trying to steer their offspring into careers in banking or computers rather than medicine. When I ask them why, they tell me they want their kids to be happy, not workaholics.

Wednesday; This is going to be a hectic day. Already there are patients waiting at my office. My second patient is an elderly man who creeps into my examining room at a snail’s pace. He has been waiting to have his hip replaced for many months. “You know, doc,” he says, “I’ll probably be dead by the time I see that fancy doctor you’re sending me to.” He has been waiting three months to get in to see an orthopaedic surgeon. Once he finally meets the specialist it will again be months before he has his joint replacement. Frustrated, I call his orthopaedic surgeon and start to rant at him. “You know, Steve,” he responds, “we can’t do too many joint replacements. The hospital won’t let us—the patients stay in hospital too long and the metal implants are very expensive.”

The conversation with the surgeon simply makes me more annoyed as I continue seeing people. Despite my perpetually out-of-date magazines and often surly demeanour, most of my patients value my opinion and frequently show it by bringing in baking and gifts at Christmastime.

Fear of joining the legions of local residents without a doctor has prompted many to ask quietly if I am planning to leave. I reassure them that I am too much in debt to leave and that I am counting on their routine blood-pressure checkups to finally pay off my mortgage (and put my kids through school—to become computer experts, I hope).

Thursday: As the week wears on, I am called to the hospital in the evening to deal with a 60-year-old man who apparently can’t breathe. The ER nurse is somewhat cryptic about his story: “Just get in

here quick, Steve, I think he’s going to crap out on us.” When I arrive, I find the man sitting up, gasping for air. He is sporting a long, grey ponytail and has a grey mottled beard. I am reminded of Willie Nelson. The nurse tells me that his family doctor started him on home oxygen because his lungs were so bad. The problem was that an open flame is not allowed with home oxygen; he forgot and decided to light up a smoke with his oxygen on, and the whole thing flared in his face. We think he has a mild smoke inhalation injury.

I start getting mad just looking at the guy. It is going to take hours of work for me to sort out what happened to him, my evening ruined because of his stupidity. I will have to decide whether he will go on a respirator, in which case he will occupy hours of my time daily and that of an intensive care nurse 24 hours a day. I realize that this guy will generate more cost to the Canadian taxpayer in a week than many other people will generate in their entire lifetimes.

The question I now face is whether I can get away with not putting this guy on a

respirator. If I put him on one, we will make him dependent on the machine and he may never get off it, living the rest of his life hooked up. This is worrisome, as our little hospital has only two respirators and we have a difficult time getting our tertiary referral hospital to accept patients like him. Who would want an old smoker stuck on a ventilator?

I run some tests, examine him and finally talk to a consultant. We agree to take a chance and leave him in our intensive care unit, but we hold off on the respirator. This is risky because, if he worsens, he could die. Finally, at 2 a.m., I get out of the hospital. “Willie” survives, but many weeks will pass before he can leave.

Friday: I arrive at the hospital to find that an elderly man has been transferred to my care. He is from a northern town and emigrated from Hungary after the Second World War. He is confused and was found wandering in the wilderness, lost. He does not speak English. Not knowing what else to do, the man’s daughter brought him to hospital. She is adamant that I “figure out what is wrong with him because he is nuts.” Speaking to the gentleman, I get the impression he just wants to go home. In the end, all he has wrong with him is some memory loss due to dementia; however, his daughter doesn’t feel she can cope with him. He languishes in hospital for days while I figure out what to do with him. I could use his hospital bed for someone else—if we had a nursing home or somewhere else to put him. Finally I cajole the man’s daughter to take him back home. This whole stay in hospital could have been prevented if they had bothered to see their family doctor a few times to treat him before he got too bad.

Saturday: The week finally ends with a call from the ER. One of my patients has come to the hospital with a ruptured lung. Years of smoking have weakened the man’s tissues so much that one of his lungs has collapsed. He can’t breathe well and is swollen up so much that I hardly recognize him. He’s in trouble. I call a surgeon at the tertiary care centre who tells me that he can’t take my patient: “Sorry, our ICU is full.” I realize there’s no way I can look after this man without expert help. I call the surgeon back and tell him he has to at least have a look at him. “OK, Steve, but he can’t stay here.” Later that day, the

man arrives back from the tertiary care hospital with another tube coming out of his chest but not really any better. I start getting panicky, and one of the nurses suggests I call the “critical care hotline.” This is manned by people whose sole job is to find specialized help for doctors like me who can’t deal with extremely difficult patients. I call. The lady on the line gives me all the usual crap: did you call the hospital you normally refer to? “Obviously, you fool, I didn’t get any help from them, that’s why I’m calling you!”

I wait for an hour, figuring a “hotline” should be a quick response system. Another hour goes by and I still get no response. I call them back. “We still haven’t located a bed for your patient—we are calling all of the hospitals in Ontario to locate a hospital that will take him.” Realizing the hotline will be useless, I start thinking about who I know who might be of help to this man. I remember that a lung specialist at our sister hospital is planning to move to B.C. but has not left yet. Maybe he will take him, as he’s leaving anyway. I call him, crossing my fingers. After a little persuasion about the desperate straits the patient is in, he finally agrees to put him in their ICU. I thank him profusely. I have just spent two hours making phone calls— not seeing patients. At last the week ends, leaving me exhausted and anxious for some time off.

Driving home from the hospital my thoughts return to the many other family doctors I have known and worked with. Some are doing very well performing cosmetic surgery at their offices, others have moved to the U.S. Still others have quit their offices and have begun working in nursing homes or in emergency rooms. So many have drifted away from the job they were originally trained to do that in continuing I feel like some sort of anachronism—a “country bumpkin” doctor who still makes

house calls. At my age, it’s not too late to change jobs—maybe I can work in industry? I resolve to find out. My immigrant parents, having come from a desperately poor country, would be disappointed if I ever left this job. They believed so strongly in the Canadian medical system—its broad emphasis on equality and fairness. Still, they would understand my wanting to leave, as the strain of the past several years has gradually worn down my idealism and optimism.

Recently the hospital paid tens of thousands of dollars to recruit a new doctor. When I arrived 10 years ago, I was recruited with nothing other than a promise of work.

My small hospital is now trying desperately to rebuild its medical staff. We are already reducing the number of services offered, due to a lack of manpower. In recruiting, the deck is stacked against us. Reduced enrolment in medical schools and fewer doctors going into family medicine will make things very difficult. Recently the hospital paid tens of thousands of dollars to recruit a doctor with the same training as myself. When I arrived 10 years ago, I was recruited with nothing other than a promise of work. Currently we have only been successful in recruiting doctors from other small towns which probably need their doctors as much as or more than we do.

REDUCING FUNDING and radically dismantling systems that had evolved over many years has resulted in providers and provider agencies no longer committed to the overall good of the Canadian population. They are now only committed to their own preservation. The situation has left the various groups fighting over the dwindling health care budget like a pack of vultures over a long-dead carcass. Inevitably, it will lead to privatization of at least some health care services, as those offered to the public become more and more inadequate.

This gradual chipping away of our health care system has done far more than just reduce the quality of the services we offer Canadians. It has reduced our confidence in ourselves as a nation. And it has left: those working in the system forever looking for an opportunity to get out. Only with a renewed commitment to medicare— and its funding—will we be able to remove the apathy and cynicism that have crept into the health care industry. Then we can rebuild our system into something the country can once again be proud of. ['ll