'There has to be a reason why you can get a hip replacement or an MRI in a week in France and yet you might wait up to two years in Canada'
Dr. Brian Day will assume the presidency of the Canadian Medical Association this year at a time of massive and unexpected change in his profession. He himself is emblematic of the new realities. The Vancouver orthopaedic surgeon is one of the country’s leading practitioners of for-profit health care. He is founder and the largest individual shareholder of the Cambie Surgery Centre, which caters primarily to injured workers funded through private insurance programs.
A native of working-class Liverpool, where he watched the Beatles’ lunch-hour shows at the Cavern, Day was the only student from his elementary school to attend university. (His father, a pharmacist, was beaten to death in the 1980s by hoodlums seeking drugs.) Educated in Manchester and British Columbia, Day has gained an international reputation as an arthroscopic surgeon. He teaches at Yale and is president-elect of the Arthroscopy Association of North America.
Day is the first CMA president in many years whose practice exists largely outside the public health care system. He insists that he was not a single-issue candidate for the organization’s top job, but he did present himself as an agent of change. Heisa tireless critic of government management of health care. His personal website opens with a quote on the dangers of public health monopolies from Canada’s most famous physician, Sir William Osler: “I do not see in Canada it would be a feasible thing if any Ministry organized taking over both the Health and the Disease of the entire community ...even in the most
favourable circumstances...there would be that absence of competition and that sense of independence ...I do not believe it would be good for the profession or good for the Public. ” The CMA is Canada’s leading medical advocacy group, representing 60,000 physicians, medical residents, and students. Because Day does not take up his new role until August, he spoke to Maclean’s editor-in-chief Kenneth Whyte not in an official CMA capacity but as an individual practitioner.
Q Would I be wrong in stating that the Canadian Medical Association, over the last 20 or so years, has been a defender of Canada’s medicare monopoly and a single-tier health insurance system?
I don’t think that’s accurate. For example, at the last annual meeting of the CMA, over 70 per cent of delegates endorsed a motion to support increased private sector involvement in the delivery of health care.
Yes, but that was in the wake of last June’s Supreme Court ruling on wait lists. A lot has changed since then. I was talking more generally about the CMA’sposition through the last couple of decades. Do you think that support for private alternatives within the public system has always been there?
I think it’s always been there. And, to me, it’s not a coincidence that in a COMPAS poll published about a week before the last federal election, 70 per cent of Canadians felt the
government should be looking to other jurisdictions—such as those in Europe—where there are systems that have a mix of private and public health care. The one group that seems to have been out of sync is government. I mean, the public and physicians seem to have a very similar percentage that support look-
'We have failed as physicians to perhaps assert ourselves in the way we should have'
ing at the private sector, and I think it’s due to a recognition that the system is not working as we want it to.
I don’t want to belabour this point, but the public attitudes have changed only recently. What I was asking is whether there has been a similar sea change in the attitudes of physicians.
I think so. Now, I would like to go on record as saying that I don’t think the private sector is going to cure the ills of the Canadian medical system. It’s just one small component that I think will help to increase the level of accountability of the public system. There i
are lots of other things wrong with the medo ical system as it’s operating in Canada, and I g don’t want to be perceived as a single-issue > person, because I’m not. £
The Supreme Court of Canada, as men2
tioned, decided lastJune that patients who need R
treatment urgently and who are on waiting ï
lists should have private alternatives to the public system.
Yes, the Supreme Court stated that Canadians are suffering and dying on wait lists and that governments across the country have shown inertia in dealing with the plight of patients. I think it is important to note that this is the same court that legalized abortion, that endorsed same-sex marriage, and that gave prisoners the right to vote. This is not a right-wing court. This is a liberal-leaning court that has said things aren’t right. In fact, one of the phrases they used is, access to a wait list is not access to health care, and they struck down the segments of the Quebec health law that oudawed private insurance for medically necessary services.
What has the impact of the decision been in the medical community?
AI think it’s pushed people to realize that finally, while governments have shown inertia, the court has rejected inertia and has ordered the governments to either clean up their act and get rid of wait lists or, if they can’t get rid of wait lists, they cannot legally force patients to wait and suffer while their health deteriorates. That’s the essence of the whole decision. Now, if governments across the country can deliver the promises of the Canada Health Act and provide health care without wait lists in an expeditious time and eliminate the suffering that the court referred to, then I would endorse that and so would every physician. Until the rationing of health care became a major problem, even those of us who entered the area of non-government health care weren’t thinking along these lines. It was only in the late ’80s and early ’90s that, as resources were being denied to patients, and doctors were not being allowed to treat patients because there was no funding to open up the operating rooms and so on, that’s when private alternatives became an issue.
You see this as a government-created problem?
It is governments that are directly responsible for the dawning of the age of private health care in this country. Governments are directly responsible through their neglect and incompetence in dealing with issues in the past. But now governments are starting to act. A large part of the reason is that the courts have given legitimacy to private care, but also there are economic realities. Provinces are now spending close to 45 per cent of their provincial budget on health care, and it’s a reality that crime is rising because health care is draining resources from law enforcement, education is suffering because health care is draining resources from education, the environment, other impor-
tant social programs. Citizens are being denied important things because of this black hole of health care. For more than 40 years, we’ve promised to give everything to everyone in unlimited amounts for free. The first government response to these economic realities was to ration health service. Well, that’s no longer acceptable to Canadians, it’s no longer acceptable to doctors, and it’s no longer acceptable to the courts.
You mentioned that this isn’t really an ideological issue anymore, and I don’t think it’s a partisan issue anymore. All the major federal parties seem ready to accept some measure of private care...
Even Jack Layton had his own hernia done!
But that said, a couple of your predecessors at the CMA have been quite critical of past Liberal governments for wrapping themselves in the Canada Health Act and demonizing doctors who worked in both private and public care. Do you expect the change of government is going to make progress easier or harder?
I think that the change of government is not likely to make a big difference, but I do think we’re at a pivotal moment in the development of the Canadian health system. We have an opportunity here that no other country has. We’re being forced to change by a combination of economics and legal requirements, but we can now design the best health system in the world. There’s an opportunity to look at the countries with universal health systems—not the United States—and take the best of what they have to offer and learn from the mistakes they’ve made and accommodate our system so that we don’t make the same mistakes. Canada can rise up the rankings from its 30th-ranked status in the world by the World Health Organization to the top five where countries like Switzerland and Belgium and France and Germany lie.
Do you think Canadians understand how low they’re ranked?
I don’t think they do, and that’s the job of Maclean’s to tell them that they’re
ranked so low!
And surely the CMA, too.
Well, you’re right. The one thing that doctors understand—because we’re the ones who are pressured—is that our patients are suffering. Having close to two million Canadians on wait lists—either waiting to see a doctor or waiting for surgery or waiting for a test—is unacceptable in a system that on the one hand ranked 30th in the world but, on the other hand, is at $4,400 per capita, [which is] more than any of those countries ranked above us. There’s something wrong with those statistics, and governments need to take a hard look at the way they have handled and managed the system over the last 20 years.
You’re not president of the CMA yet, but you are a member of the Canadian medical community. Is it not something of a disgrace that it took the judiciary rather than the medical establish?nent to come out and say that the waiting lists in Canada had reached a point of inhumanity?
Well, I’ve been saying it for a long time, and I think a lot of my colleagues have been saying it for a long time.
I’ve looked at CMA clippings going back 10 or 20 years, and I didn’t see anywhere near as clear a statement as we got out of the Supreme Court.
I think that doctors, by nature, tend to want to make things work within a system, and it’s a Canadian trait to be calm and col-
'Privatization is too American? Why would the 30thranked system want to copy the 37th?'
lected and try and work things through the system, but that has failed. I think you’re right, we have failed as a nation, and particularly we have failed as physicians to perhaps assert ourselves in the way we should have. I think it’s wrong to blame doctors for the mess that governments have gotten us into, and I think that one lesson we need to learn is that to have allowed governments over the last 25 years
to rely on health policy experts—for example like those who said one of the problems is too many doctors and let’s close the medical schools, and here we are now with a legacy of a shortage of doctors—I think that we have a duty as physicians to be more assertive in letting the government know we have a better understanding of priorities in health care and health care delivery than individuals who have been advising them and have gotten them into this mess in the past.
With health care costs in Canada—total private and public spending—up, I think, over $130 billion a year, and still climbing, even with some private outlets, is the ability to provide health care outstripping our ability to pay for health care?
"Analysts told governments there were too many doctors. Now we have a major shortage."
I think so. But there’s a lot we can do. We’ve got to learn why France can spend more than 40 per cent less per capita than we do and have no waits in their public system. I mean, there has to be a reason why you can get a hip replacement or an MRI within a week in France and yet you might wait between six and 18 months or two years in Canada, and yet they’re spending 40 per
cent less than us. And I’m talking about public systems here. For some reason we have bought into this sales pitch, this propaganda, that we have a wonderful health system, when, as the Supreme Court noted, many patients are suffering and dying on wait lists. And one of the reasons we’ve been stuck is because any hint of reform has been attacked as a trend toward Americanization. My answer to that is the World Health Organization ranks the U.S. system 37th in the world, and why would the 30th-ranked system want to copy the 37th when we can copy one of the top five? And so I think reform is coming. Governments are nervous about how to go about this, but we already see at least three provincial governments being proactive in that regard.
You’re speaking of Alberta, B. C. and Quebec?
Yes. And I think that other governments will be forced to follow suit. They cannot sustain the costs of health care while crime increases and education is starved of funding.
I just want to ask you one more question about the private/public mix. One of your predecessors as president of the CMA, Dr. Albert Schumacher, I think, suggested a 95/5 per cent public/private mix. Does that sound right to you?
Well, we already have a 70/30 mix if you count dentistry and drugs. I suppose Dr. Schumacher must have been talking about the physician, or the direct delivery of what we define as medically necessary services, and I think it needs no more than five per cent or 10 per cent. In other words, there’s no desire on my part, nor on the part of most doctors, to have a large component of private funding and delivery of health care, but I think that the public system needs some yardstick by which it is graded, measured and called to be accountable, and that has been lacking until the last few years. And to me, the so-called care guarantees and the contracting out are perfectly valid mechanisms to embrace the private sector. In other words, the patient doesn’t necessarily have to pay out of their pocket for anything, that simply by allowing the private sector to compete alongside the public sector will help make the public sector better.
QThere’ve been some articles in the Canadian Medical Association Journal and other places about doctors and academics having financial interests in some of the drugs for which they’re writing guidelines. How big a concern is that, and is there enough being done about it?
I think that it’s important. I believe in disclosure. For example, I’m a surgeon, and as a surgeon in our current system, a public system, if I see a patient who needs surgery,
and advise that patient to have surgery, I will stand to make a financial gain. A bad doctor will abuse that type of situation. These issues really speak to the ethics of physicians. If I say to you, ‘T think you should have this medication, but I must warn you that I did research for this drug and I was actually paid something by the drug manufacturer,” then you as a consumer can choose whether to accept the recommendation of that drug. I think it’s all about disclosure, and when there’s a failure to disclose I think that’s wrong, but I think the reality is we live in a capitalist society and the drug and equipment manufacturers are where most of the designs of new equipment and the generation of new technologies and drugs come from. We need their help in funding research. I think it all comes down to disclosure.
A CMA survey reported that half of the doctors in Canada were in an advanced stage of burnout, that one in 10 were using sedatives and one in five using tranquilizers. Other studies showed high rates of suicide among doctors. The CMA is a professional association, and from what I’ve been able to see it has nothing but voluntary programs to combat any of this. Is that something that needs to be addressed?
APart of the reason for that is overwork and unhappiness with the way our practices have developed. We have a doctor ratio of 1.9 per thousand, and that compares with 3.5 per thousand in a recent survey of 12 European countries. And doctors are leaving the workforce, they’re retiring early, and that puts more load on the existing workforce. What is the reason for that? The reason is that 15 to 20 years ago health policy analysts told governments that there were too many doctors and doctors were the cause of the problem, so they cut back on medical schools and now we have a major shortage of doctors. So that’s not easily fixable. You can’t just produce new doctors in a year or two.
There’s no question the system has problems, but when you’re shown statistics like this about the health and well-being of doctors, surely doctors have to take some responsibility for it themselves, and surely as a professional organization the CMA has to take some responsibility for its members. This voluntary approach doesn’t seem to be working.
Well, I think that as a national association, yes. As you know, the jurisdiction of health care is provincial, and I think all provincial colleges of physicians have programs in this regard. Could they be better, and could they be more forceful or more effective? I’m sure they could be, and I think you raise a very valid point. M