HEALTH

OVEREATERS, SMOKERS, AND DRINKERS, THE DOCTOR WON’T SEE YOU NOW

NICHOLAS KöHLER,BARBARA RIGHTON April 24 2006
HEALTH

OVEREATERS, SMOKERS, AND DRINKERS, THE DOCTOR WON’T SEE YOU NOW

NICHOLAS KöHLER,BARBARA RIGHTON April 24 2006

OVEREATERS, SMOKERS, AND DRINKERS, THE DOCTOR WON’T SEE YOU NOW

HEALTH

Health care is meant to be open to everyone equally. But some doctors question, even deny, treatment to those with certain vices.

NICHOLAS KöHLER

BARBARA RIGHTON

It's a touchy subject. So touchy that after an hour-long interview, one Calgary orthopaedic surgeon decides he wants to remain anonymous. From New Brunswick, where a surgeon recently cancelled an operation on a crippled man's leg, a Moncton Hospital spokesperson calls asking Maclean's to stop trying to contact the doctor. At issue: health care for patients with self-destructive vices-

overeating, smoking, drinking or drugs. More and more doctors are turning them away or knocking them down their waiting lists— whether patients know that’s the reason or not. Frightening stories abound. GPs who won’t take smokers as patients. Surgeons who demand obese patients lose weight before they’ll operate, or tell them to find another doctor. Transplant teams who turn drinkers down flat. Doctors say their decisions make

sense: why spend thousands of dollars on futile procedures? Or the decision is the product of frustration: why not make patients accountable for their vices? Others call it simple discrimination. But in a health system with more patients than doctors can treat, where doctors have discretion over whom they’ll take on, some say it’s inevitable that problem patients will get shunted aside in favour of healthier, less labour-intensive cases.

So here’s the question: if people won’t stop hurting themselves, can they really expect the same medical treatment as everyone else? Health care in Canada is supposed to be about equal treatment for all comers. For some doctors, however, there are patients who are less equal than others. Winnipeg GP Frederick

Ross is one. In 2002, he told his patients he’d no longer see them if they continued smoking. “I said, this is stupid. I told my patients, you have three months to quit or I am going to ask you to find another doctor,” recalls Ross, a genial man. “I said, your smoking is impeding my progress in treating you.” Some people left in a huff. One challenged him on the basis of human rights (a tribunal later threw the case out). Others—hundreds, he says—stayed and quit smoking.

Cutting out the cigarettes might have helped some patients avoid an appointment with Dr. Alberto de la Rocha. As a former thoracic surgeon in Timmins, Ont., de la Rocha operated on lung cancer patients for 17 years before quitting. “I burned out in an atmosphere of indifference and lack of accountability-public and personal accountability,” says de la Rocha, who is now a medical officer of health in northeastern Ontario. Smoking, says de la Rocha, goes hand in hand with entitlement. “It goes like this: T am sick. You are the guy who is supposed to cure me. You are going to do that in whatever condition I am in and that is my right.’ ”

Not in my operating room, said de la Rocha, who decreed that his lung cancer patients would have to minimize their risks of a heart attack on the table or of post-op respiratory complications by not smoking for at least five weeks before surgery. “Your surgery will be booked at a time when you are prepared for it,” he told them. “And if you continue smoking, I am afraid you are going to have to look for a surgeon hungry enough or foolish enough to take your case as it is.” (De la Rocha is no stranger to controversy. In April 1993, he received a suspended sentence, three years probation and a six-month suspension of his medical licence for his role in the October 1991 death of a 68-year-old

lung cancer patient. He admitted dosing her with a noxious substance—potassium chloride—as well as morphine, on her deathbed. The woman’s sons, who did not know at the time about the deadly shot, said they were very satisfied with his humane treatment.)

Meanwhile, Dr. Paul Salo, a Calgary orthopaedic surgeon, says he’s reluctant to proceed with surgery on “inveterate” smokers or the “massively overweight.” Nicotine impairs bone healing, Salo explains, before adding that the failure rate in operations where bone must heal to bone is five times higher among smokers. Indeed, even the risks associated with surgery are high enough, Salo says, to require smokers to quit three months before an operation. If they don’t? He goes ahead, but warns: “Look, if this

doesn’t heal, I am not going to be very happy and you are going to be miserable.” Salo is most definite when it comes to turning down drug addicts. “I have the option to say, T can’t form a therapeutic contract with you,’ ” he says. “If someone has an elective problem and they are not going to comply with my treatment recommendations, I am under no obligation to take them on.” Canada’s provincial colleges of physicians—the professional regulatory bodies governing doctors’ conduct—have no specific policies in place to stop the practice of denying treatment. “The physician makes recommendations based on what is in the best interest of the patient’s health,” notes Dr. Bill Pope, registrar of the College of Physicians and Surgeons of Manitoba. “By refusing to accept advice related to major issues with the patient’s health, the patient is saying to the doctor, I don’t believe you, I can’t trust you, I can’t accept you—and is basically saying I can’t work with you.”

Dr. Ruth Collins-Nakai, president of the Canadian Medical Association, stresses that doctors will always provide care in emergency situations. She adds, however, that in cases of “lifestyle-induced problems” brought on by such habits as smoking, “the doctor cannot change those things without the cooperation of the patient. And if the patient isn’t willing to co-operate, then it becomes very frustrating for the doctor to have to continue looking after the patient.” And, though she says doctors who drop such pa-

‘SMOKING OR DRINKING IMPACTS ON YOUR HEALTH CARE. THAT’S JUST THE WAY THE WORLD IS.’

SOME DOCTORS HAVE SAID TO PATIENTS, ‘DON’T BREAK MY SCALE. DON’T SIT ON MY CHAIR.’

tients are rare, she adds that continuing to treat people who won’t change “may not be the wisest use of the few resources we have in terms of doctor-availability.”

Doctors across the country told Maclean’s of colleagues who would not take “unhealthy patients”—smokers, drinkers and the obese— because caring for them would be too complicated, and too much of a burden for their already overcrowded practices. Such patients might, in other words, take longer to treat, reducing the number of patients a doctor can see and bill for. The consequence is an entrenched tendency to choose the gym-goer, the moderate connoisseur of red wine and the non-smoker. Says Dr. Edward Schollenberg, the registrar of the College of Physicians and Surgeons of New Brunswick:

“The idea that smoking or drinking or excess weight impacts on your health care is just the way the world is.”

NOWHERE IS this dictum truer than in the realm of the overweight and obese.

Dr. David C.W. Lau, an obesity specialist at the University of Calgary, says there are sound medical reasons to explain why doctors are less likely to want to operate on people who are heavy. “Operating on them would pose a significant increased risk of complications,” says Lau. “Surgeons don’t like to deal with complications and none like to see their post-op complications go up.” The Calgary orthopaedic

surgeon who doesn’t want his name used has done thousands of knee and hip replacements on overweight people—but he’s not pleased about it. “Prostheses have a limited lifespan,” he says. “If patients are overweight, they will wear them out much faster.” Plus, he says, “Historically, obese people are at higher risk for surgery. There is a higher complication rate. There are healing and pulmonary issues. And they don’t mobilize as fast as thin people.”

But some doctors say there are more insidious factors keeping big Canadians from receiving the same treatment as the rest of us: discrimination. Bluntly put, fat people—a group that represents over 50 per cent of Canadians—are more likely to be discriminated against by the general public than drinkers and drug addicts (somewhere in the four per cent range) or smokers (22 per cent) because their affliction is so no-

ticeable (all numbers are from Statistics Canada). And the medical community is as guilty of it as the rest of us. “The attitudes in the medical profession are surprisingly wanting,” says Dr. Robert Dent, who heads up a weightmanagement clinic at the Ottawa Hospital. “The feeling is that if somebody’s overweight, it’s because they’re eating too much and they’re lazy.” He adds: “If we want to use older lan-

guage, we find that overweight people are considered guilty of two of the seven deadly sins—sloth and gluttony.” The consequences of such discrimination can be subtle—or not.

Dr. Arya Sharma, an obesity specialist at McMaster University in Hamilton, has heard his patients complain of doctors who’ve told them, “Don’t break my scale, don’t sit on my chair.” He adds: “It’s not just doctors—it’s nurses, it’s dieticians. Health professionals don’t like obese people.” (For that matter, says eating disorders statistician C. Laird Birmingham at the University of British Columbia, “Obese people hate obese people.”)

The problem is so ingrained in the medical profession that even those doctors who specialize in obesity dislike their clients, according to a 2003 Yale University study. Questioning 329 members of the North American Association for the Study of Obesitymany of them doctors or obesity counsellors—at their annual meeting in Quebec City, researchers found a pro-thin, anti-fat bias based on something called the Implicit Association Test. Subjects were given a list of words that fit into one of four categories. After a practice run where they paired such things as “flowers” with “good” and “in-

sects” with “bad,” the obesity specialists jumped to associate “fat people” with words like “slow,” “lazy” and “sluggish,” and “thin people” with “determined,” “motivated” and “eager.” The study concluded that “the stigma of obesity is so strong that even those most knowledgeable about the condition infer that obese people have blameworthy behavioural characteristics that contribute to

TEHNOLOGY IS SO EXPENSIVE. THE SYSTEM WILL RUN OUT OF MONEY UNLESS PEOPLE CHANGE.

their problem,” even extending to core characteristics of intelligence and personal worth.

Such notions represent an antiquated view, says Dent. In a study aimed at matching the different types of obesity with some 600 different genes that he is conducting with Ruth McPherson, director of the Lipid Clinic at the University of Ottawa Heart Institute, Dent is looking at 1,000 overweight and obese patients cross-referenced with 1,000 patients who are underweight. About half of the thin people “are eating as much or more than our obese patients,” says Dent, who then adds the counterpoint example: “We occasionally have some people who won’t lose weight on 500 calories a day.” (The average Canadian’s daily intake is about 3,000 calories.) Some physicians call this the burden of geneticssomething Dent refuses to do. “We don’t call those bad genes because they caused the human race to survive across many famines in the history of humanity. A skinny guy like me wouldn’t have made it.”

Late last year, England weighed in on the question of hip and knee replacements for the obese (who tend to put more strain on artificial joints) when three health boards in East Suffolk said they’d no longer approve them for fat people. “We cannot pretend that this wasn’t stimulated by the pressing financial problems of the National Health Service in East Suffolk,” Brian Keeble, the director of

public health for Ipswich Primary Care Trust in East Suffolk, said at the time. While local doctors threw their support behind the health board’s move because replacing weight-bearing joints in the obese is risky anyway, the decision’s motives were still about the bottom line.

There’s no arguing that in Canada, too, health care costs are skyrocketing. In 2000, Statistics Canada added up the total bill at $979 billion. The Conference Board of Canada predicts that, when adjusted for inflation, health care costs will total $147 billion in 2020. Also inarguable: vices such as a penchant for high-fat foods and cigarettes are really ringing up the cash register. The fallout from obesity, says UBC’s Birmingham, now accounts for five per cent of our total health care dollars, or $5 billion a year. “You’ve heard that phrase ‘obesity is the new smoking,’ ” says Ross in Winnipeg. “Well, private health care is going to come into Canada because our public system is going broke over obesity.”

The ultimate costs of bad behaviour? A new heart—

$80,000. Liver? $150,000.

Lung? Somewhere in the neighbourhood of half a million. Indeed, Dr. Gary Levy, the medical director of Toronto General Hospital’s multi-organ transplant program, says unhealthy living is simply unaffordable: “We are getting to the point where we can extend

life. And that is something society is going to have to come to grips with because technology is more and more expensive. If we can’t change people’s behaviour, look, I am going to tell you, we are going to run out of money. We probably have run out of money.” Levy says 75 per cent of the patients he sees need transplants because of their own excesses.

The burden on our health care system is so high that some propose making viceplagued patients pay. “This is an issue of behaviour and choice,” says Nadeem Esmail, a senior health policy analyst with the Fraser Institute. “People can choose to alter their behaviour, can choose to go to the gym more often—these are choice things.” If you can’t persuade yourself to live healthier, or so the argument goes, why make the rest of us foot the bill? “We have a universal program, really, to protect people from the fickle hand of fate,” says Esmail. “And so the optimal solution is to say to them, your behaviour is going to incur higher health costs over your lifetime and so, because you can control this, you should be paying a higher health premium.”

For GPs, it’s also a question of a volumedriven health care system that gives them little incentive to tackle time-consuming, complex cases. The more time a doctor spends with a patient, the fewer patients can be seen and the less revenue generated for a doctor’s practice. It’s the kind of bind that leads to frustration. “Many of these individuals continue their lifestyle unabated,” says Lau. “And not only are they not losing weight or hold-

THE REALITY? DOCTORS CAN

CHOOSE THE BEST CANDIDATES

FOR ANY ELECTIVE PROCEDURE.

ing their weight, they’re continuing to gain weight while they’re on the surgical waiting list. So, between the time the surgeon sees them and the time they’re operated on, there may be a significant increase in weight.” In the words of the anonymous Calgary knee and hip surgeon, doctors “feel like we are beating our heads against the wall” trying to treat chronically overweight patients in a climate of underfunded, turnstile medicare.

And then there’s the garden-variety prejudice on the part of doctors who believe their patients are unhealthy because they can’t control themselves. “Doctors can pick and choose their patients because we have a situation where there are more patients than doctors can handle,” says Dr. Andreas Wielgosz, a cardiologist at Ottawa Hospital. “Can

they pick the best candidates? Sure.” How do doctors pick and choose? The Calgary orthopaedic surgeon says he never refuses to do surgery on overweight people. But, he says, knee and hip replacements are elective. “They are not a matter of life and death.” And? “A doctor can sell an operation any way they want. If I see someone with a so-so joint and they are overweight, I may tell them to wait.” How long? His waiting list is one to two years.

tried to tell him that I had already lost quite a bit of weight and that I hoped to lose more.” He wasn’t interested, Bartlett says. “I didn’t choose to be like this,” she adds.

In New Brunswick, a surgeon decided Robert Randall could wait—forever. Illiterate, 42 years old, Randall lives with his wife and two of their four children in a tiny crossroads called Albert Mines, about 50 km south of Moncton. Randall used to fish for lobster and scallops on the Bay of Fundy. But he hasn’t done much of anything except wallow in pain since the night in February 2004 when he drove his snowmobile into a tree, fracturing his right femur and shattering his knee. The throttle stuck open, Randall explains, but he also admits he’d been drinking. The accident earned Randall an ambulance ride to a Moncton hospital and emergency surgery to repair a mangled leg. That was soon followed by a second surgery to fix the damage Randall did by trying to balance on his good leg while chopping the wood he uses to heat the family home. A third surgery, during which orthopaedic surgeon Dr. Steven Massoeurs immobilized him in a full body cast, didn’t “take,” says Randall—despite the fact that he faithfully used crutches and “went right to the letter on what the doctor told me.” Well, not quite. Randall is a lifelong smoker (he began at age 10) who refuses to give up despite his surgeon’s warning that nicotine would slow the healing process. “I said, ‘I’ve got all the time in the world,’ ” Randall says, obviously failing to grasp that “slow” might mean not at all. In January, his fourth surgery —the one he thought would involve a bone graft—was cancelled with two days’ warning, says Randall, after Massoeurs’ assistant called to say the surgeon wouldn’t operate. There are no plans to reschedule.

ONE PATIENT whose lifestyle ran afoul of her doctor is 45-year-old homemaker Kelley Bartlett, of Burlington, Ont. Bartlett is forthcoming about her weight— she’s five foot eight and weighs 243 lb. Overweight since her early 20s, Bartlett recently lost 50 lb. and was feeling pretty good about herself. Then her GP diagnosed a hernia and sent her to a general surgeon for an assessment. “The hernia is quite large,” she says, “and, yes, there is fat on my stomach too.” The surgeon was brutal. “After the surgery, you will still have a bulge,” he told her before adding: “I am not a plastic surgeon—I don’t do tummy tucks.”

Bartlett was struck dumb. “He couldn’t have been any blunter. He said there was only a 50 per cent chance of success because of my weight,” she says. “He told me to go away and lose weight before I saw him again in April. I

Randall says he doesn’t understand why his doctor cancelled the procedure. Schollenberg, of the College of Physicians and Surgeons of New Brunswick, says the answer’s pretty simple. The central issue “was whether the patient’s lifestyle-including his twopack-a-day habit—would impact on the results of surgery.” Randall’s repeated surgeries didn’t help. “Doing that many procedures in the same area is asking for trouble—and it is compromised significantly

by the patient smoking."

THE CMA’S NUMBER ONE RESPONSIBILITY: CONSIDER THE WELL-BEING OF THE PATIENT

Whether the benefits of a procedure outweigh the risks is up to the doctor, not the patient, adds Schollenberg. “Robert Randall thought he was entitled.”

That doesn’t help Randall much. In constant pain and with a right leg that now “bows” with his weight, he survives on welfare, the morphine he gets from his family doctor, and a steady stream of hand-rolled cigarettes. “Just sitting here staring at the walls,” says Randall, “if I didn’t smoke, I would go crazy.”

All of this might come as a shock to those health professionals who side with the notion of justice for all. “If, in our medical system, we start blaming people for whatever condition they have, then we can probably close down our hospitals—because 90 per cent of the medicine that we do is related to people’s lifestyles,” says Sharma, the Hamilton obesity specialist. The move in the U.K. to restrict surgical procedures based on weight, says Diane Finegood, scientific director of the Institute of Nutrition, Metabolism and Diabetes for the Canadian Institutes of Health Research, “disturbs me greatly because I am wary of leaving such decisions up to the physician.”

But that is exactly what’s happening right here, right now. Dr. Pete Sarsfield, the medical officer of health for the Northwestern Health Unit in Ontario, is one doctor who says he’s known colleagues to decline problem patients. “And I have sympathy for those docs because I know what it’s like to treat addicts—you pick up the pieces and they don’t change their behaviour,” he says. Sarsfield has campaigned tirelessly against such destructive behaviour as smoking, but he still doesn’t agree with doctors who won’t treat smokers. “In this job, we don’t have a right to pick and choose. We have a duty of care. Where does it say in the Hippocratic oath, T will only treat people who are well?’ ”

Ross, the Winnipeg doctor who dumped his smoking patients, doesn’t mind the notoriety he’s generated with the move. When he first tossed out his ultimatum four years ago, his colleagues kept silent. But the media didn’t. CNN called him. So did a TV station in New Zealand. Ethicists, meanwhile, lined up to condemn him, citing the Canadian Medical Association’s first fundamental responsibility: “Consider first the well-being of the patient.” Said Ross at the time, “I have been criticized, vilified and downright denigrated for taking this stance.” Still, he never blinked. After all, the CMA’s fourth fundamental responsibility is: “Consider the wellbeing of society in matters affecting health.” Says Ross, “Forty-four thousand people a

year are still dying in Canada of smokingrelated disease. I don’t want to hear any more excuses. We can fix this.” Why don’t more doctors follow his example with more tough love? “Because we are seen as the nice guys. That is our role.”

So when can a doctor expect an individual patient—the smoker, the overeater, the boozer—to take that long, hard look in the mirror and drop the vice? “Look,” says Levy, “We are all guilty. All of us do things that are not good for us. The reality is we go to fast-food restaurants. We drive too fast. We should cut our salt intake. We need to educate all elements of society. We have an obligation: we have to put the brakes on bad

living styles. We need to convince people of the value of living healthy lifestyles and what the cost is, not only to themselves and their families, but to society.”

De la Rocha is a little more pointed. There are some instances when medical science and expertise are just not good enough to fix the problem, he says. “We have become a society that is complacent, that is soft, that is demanding, that has unrealistic expectations, and that has a deeply ingrained sense of entitlement. We have to say to patients, T am sorry, man, you are going to have to become responsible for your own health and that means addressing the issue of your tobacco addiction, addressing the issue of your sedentary life, addressing the issue of your very erratic and unhealthy eating habits, addressing the issue of your excess drinking. Do something for yourself.’ ” M