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Looking for Solutions in Health Care for 2006 and Beyond

Our health care system needs to change to accommodate new demographics, new technologies and new pharmacologic advancement.

The roots of compassion and caring in health care should not change however, and it is with this in mind that the dialogue of change should be had surrounding health care.

How can we adapt to different needs that emerge as our population ages?

How can we  find sustainability in the midst of so many new advancements?

How can individuals become more empowered in serving their own health care needs?

What role does the individual have in enabling the  health care of others  beyond paying taxes?

Many questions like these need to be answered and if we are willing to look with open minds at the problems within our health care system, and beyond political posturing, then we can find new  solutions to take us further into this century. 

 

 

 

 

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Wednesday
Mar072007

The Blame Game

We often hear politicians or medical leaders use the phrase, “we are working together to find solutions”….and it makes me shudder….because I’ve heard this phrase mostly when things aren’t going so well and there is an attempt to put a positive spin on a negative situation or when there really isn’t much of anything positive to say at all. This little phrase raises red flags for me.

The belief that the sum is greater than the parts may be true sometimes, but it still takes the efforts of all the individuals involved. This could not be truer than in health care.

Often, the contributions of patients to their own health care is overlooked or is unmentioned as we look to blame various entities for the problems we face in burgeoning health care budgets. It is the “inefficiency” of the system that is to blame; it is the bureaucrats who are to blame; it is the physicians who are to blame; it is lack of EMR and IT that is to blame; it is the government that is to blame and on and on.

Sometimes it seems that patients are considered incapable of making good decisions about their health. There is rarely a clear expectation mentioned by government or medical organizations that patients are responsible to some degree for their well being and their health and decisions surrounding it.

Responsibility in health care should include an expectation that patients will use a “health conscience” and yes, I realize this entails health education, health promotion, health access but above all else, it requires patients to be engaged and empowered in their own health care.

So when it comes to the increased number of patients with diabetes and obesity and all their related complications including end-stage renal disease, cardiovascular disease, coronary disease, how can we empower individuals with the responsibility of their own health?

Some people suggest a society-wide crusade against obesity like the anti-smoking campaigns but the truth is that one can survive without ever taking another cigarette but living without food is nigh impossible…..pretty hard to go off food “cold turkey” or with a patch.

And if food is our society’s addiction, whose fault is it? Is it government’s fault that patients consume too many calories for their genetic predisposition? Is it the doctor’s fault for not monitoring the patient’s food intake or exercise more closely? Will a nurse in charge of monitoring diabetics belonging to the health team be able to impart self-discipline and the motivation to improve eating habits and lifestyle habits? Maybe for some.

Let us not kid ourselves; eating is a complex activity with many driving forces.

Dr. Lorraine Lipscombe, research fellow with Toronto’s Institute for Clinical Evaluative Sciences and lead author of a paper published recently in The Lancet, suggests that improved diagnostic techniques for identifying diabetes among younger people more often might be showing a greater increase in diabetes in this population. This may be true but we should be looking at the social factors that are creating the rise in obesity and patients must be educated that their health belongs to them.

A new national survey of 1,500 adults conducted by Leger Marketing recently showed that 31% said they make “a conscious food or drink choice they know will not agree with their body at least once a week”. Eight percent said they do it every single day. The lead- in sentence for the article from the Can West News Service is “Millions of Canadians commit the deadly sin of gluttony on a weekly basis, and they do it knowing they will suffer uncomfortable consequences”.

So what to do with rising rates of diabetes? The Health Council of Canada thinks it knows. Well, at least it actually acknowledges the contributions that patients could make instead of leaving patient responsibility out of the equation.

http://www.healthcouncilcanada.ca/docs/rpts/2007/HCC_DiabetesRpt.pdf

On page 11, the report, “Why Health Care Renewal Matters: Lessons from Diabetes”, looks at four players in the health care system: public policy makers, health care system managers, health care providers…….and……last but not least……individual Canadians (and their families and communities).

Finally, some mention of patient responsibility.

The report goes on to describe what these four groups affect when it comes to health care including how much people know about their health and how to prevent illness; how and when people seek needed health care; how appropriately health care meets people’s needs; how effectively people are empowered to manage their own health; and how healthy people are.

Somehow I doubt this will come cheap. The worry seems to be that if one in 10 Ontarians (1.2 million people…almost the same number as people without a family doctor) develops diabetes it could cripple the health care system…. one disease, crippling the health care system not to mention the billions spent on the Big Five already without major improvements in wait times. Seems to me we are there.

If we have looked ahead to understand the expense of treating this disease, we should also look at the cost of predicting disease.

In the March 2007 issue of Scientific American, a very insightful piece, “New Predictors of Disease” by Abner Louis Notkins, focuses on predictive antibodies that appear in the blood years before people show symptoms of various disorders including Type I diabetes, Rheumatoid arthritis and celiac disease and other autoimmune diseases.

We have entered the era where the ability to forecast someone’s life and death is possible and ultimately it will be the patient who chooses how they manage the information they possess and the information they could possess, just as they choose what they eat.

Despite the mantra that “working together, we will find solutions”, individuals ultimately must make decisions and choices regarding their health and are the true pillars of health care transformation. They should be given the latitude to engage in their own care.

Canada has changed, it is not 1967 anymore and it is nobody’s fault.

Wednesday
Feb282007

Herding Cats

It has been said that leading doctors is like herding cats. Why does this matter? It matters because if you want to supply adequate numbers of physician providers for patient care then you must understand how to create an environment in which these people can thrive and do what they are trained to do: take care of patients.

In the March 2007 volume of Harvard Business Review, an article caught my eye:

Leading Clever People” by Rob Goffee and Gareth Jones.
How do you manage people who don’t want to be led and may be smarter than you?

I’ll provide a few sections for your interest and although it doesn’t apply fully to the medical world and you may want to argue that physicians are not "clever people", there are some interesting parallels:

Franz Humer, the CEO and chairman of the Swiss pharmaceutical giant Roche, knows how difficult it is to find good ideas. “In my business of research, economies of scale don’t exist,” he says. “Globally today we spend $4 billion on R&D every year. In research there aren’t economies of scale, there are economies of ideas.”

For a growing number of companies, according to Humer, competitive advantage lies in the ability to create an economy driven not by cost efficiencies but by ideas and intellectual know-how. In practice, this means that leaders have to create an environment in which what we call “clever people” can thrive. …..

If clever people have one defining characteristic, it is that they do not want to be led…..The challenge has only become greater with globalization. Clever people are more mobile than ever before.

.... 

Given their mind-set, clever people see an organization’s administrative machinery as a distraction from their key value adding activities. So they need to be protected from what we call organizational “rain”- the rules and politics associated with any big-budget activity.

….

Savvy leaders take steps to streamline rules and to promote a culture that values simplicity.

….

Seven Things You Need to Know About Clever People

Leaders should be aware of the characteristics most clever people share, which collectively make them a difficult crew to manage.

They know their worth…. You can’t transfer the knowledge without the people.

They are organizationally savvy. Clever people will find the company context in which their interests will be most generously funded. If the funding dries up, they have a couple of options: They can move on to a place where resources are plentiful, or they can dig in and engage in elaborate politics to advance their pet projects.

They ignore corporate hierarchy. If you seek to motivate clever people with titles or promotions, you will probably be met with cold disdain. But don’t assume this means they don’t care about status; they can be very particular about it, and may insist on being called “doctor” or “professor”.

They expect instant access. If clever people don’t get access to the CEO, they may think the organization does not take their work seriously.

They are well connected. Clever people are usually plugged into highly developed knowledge networks; who they know is often as important as what they know. These networks both increase their value to the organization and make them more of a flight risk.

They have a low boredom threshold. In an era of employee mobility, if you don’t engage your clever people intellectually and inspire them with organizational purpose, they will walk out the door.

They won’t thank you. Even when you’re leading them well, clever people will be unwilling to recognize your leadership. Remember, these creative individuals feel that they don’t need to be led. Measure your success by your ability to remain on the fringes of their radar.

Thursday
Feb222007

FHT in a Fit

Let me start this entry by making it clear that I have never had any problem working alongside nurses; no problem that I am aware of, not in more than twenty years.

I respect the nurses I have worked with for what they are trained to do and I respect the different nature of their occupation and their knowledge and ability to bring important patient information to a team of health care providers.

The whole power struggle issue that I heard about as a medical student from various sources was never apparent to me except on occasions where it seemed that “orders” written on the patient’s chart had not been carried out as written or in OR situations where banter between surgeons and some nurses had uncomfortable undertones for one reason or another. Some reasons were probably better left unmentioned to junior staff like me.

But I don’t think these issues are specific to nurse/physician relationships. I believe these difficulties would be found in any organization where there are people interacting with co-workers in stressful situations or in situations where there is potential for confusion.

The old expression “Too many cooks spoil the broth” only points to the potential for difficulties that occur when communication gets muddled or when people bring different perspectives to the same job. It is not surprising at all to see the flagship Family Health Team in Brighton including Dr. Jim McLean, who also serves as the chair of the health ministry’s action group on family health teams, in disarray as one newspaper headline put it.

This week’s ministry inquiry at Brighton comes after a health nurse practitioner was fired without cause by the husband-and-wife team of Dr. Jim MacLean and Dr. Sue MacLean, and executive director Joan Dorland. This is according to Gail Prue at The Independent.

“We’ve all been holding our breath that something like Brighton wouldn’t happen,” said Jane Sanders, executive director of the Nurse Practitioners’ Association of Ontario (NPAO). “But the integration of nurse practitioners on an equal footing with doctors in health teams is a very real issue now.”

Part of the problem appears to be that there is discrepancy over how “equal” various health care providers are and the ability for doctors, NPs and RNs to have “equal power” within a FHT. Some say that this would be avoided by having better governance in place with NPs having a clear job description; by having annual general meetings; by annual performance reviews; by a properly constructed FHT board and a conflict resolution process.

Of course, all the associated administrative costs of running a FHT can’t be ignored which is why the ministry signed a cheque for $563,095 to pay for the operation of the Brighton Family Health Team in 2006/07.  How much real health care this could provide to patients is fodder for another discussion.

Having worked in a variety of settings from locums to rural practice to urban and suburban and caring for patients in long term care institutions or visiting patients in hospital, I have never had a contract. Nor did the government provide us with financing to make sure fellow docs could work out disagreements in a professional and amicable manner with a paid for governance plan. We just did. We just did because we were equals. There was give and take, and equal responsibilities, although sometimes different responsibilities.

So I am stymied by how Doris Grinspun, executive director of the 80,000-member Register Nurses Association of Ontario, seems to imply that the problem in Brighton is about contracts while the real reason is likely much deeper. She says, “The nurse practitioners have got crappy contracts. The case in Brighton is a good example.”

If colleagues are truly equal, with equal training and equal understanding of their responsibilities as created by their experience and “gruelling” background, and equally professional, then there will be mutual understanding.

Experienced RNs trained to the highest level of leadership and skill under a grueling two-year university program and who are trained to provide “80% of a doctor’s duties” may not be in a position to share equally in the leadership of a FHT when a physician’s training requires at least double this training along with a very gruelling and intense residency.

It is difficult to have cohesive work in a setting where many people want to lead for a variety of reasons. It has been my experience that the best work gets done when one or maybe two people lead while the others assist in a variety of ways, even though their intelligence and their abilities could have enabled them to lead as well. Rotation in leadership has always been the norm within medical circles ie one chief of staff, head intern, head resident, team leader.

The idea that various members of a FHT should all be “leading” can only lead to resentment, poor communication and poor performance and patients left wondering why they can’t get the care they deserve.

Ontario Health Minister George Smitherman has commissioned a special task force to come up with the answers about NP integration.

The task force, co-chaired by Ontario’s former chief nursing officer Dr. Sue Matthews and McMaster University professor Dr. Alba DiCenso, is due to report within three weeks.

And we can know that this will come with a price tag for taxpayers and a sign of things to come in the transformation of health care to a tangled, expensive web with lots of bureaucratic ties that do little to support patients.

 

Go ahead, blast me. Tell me that nurses are equal to physicians and should have "equal power sharing" within FHTs.....and I'll tell you that if NPs were fully equivalent to physicians, there would be no separate NP program and family physicians would not have been required to take additional years of training to provide "safe" service to the public. 

If NPs want to be treated equally, they should be setting up their own practices, taking the same risks as physicians do to open their practices, paying for their office overhead, and paying for their own disability  benefits and setting up their own "contracts".

 

 

 

 

Wednesday
Feb142007

Patient....With a Capital "P"

When I am the bearer of bad news to patients, I usually tell them that they are not a statistic; that they are an individual who may have a different outcome than what probability would predict. I do this because I believe in giving hope. Without hope, there might as well be no medical system at all.

Whether it is a possible outcome or how long they are going to wait for treatment, it is important to be truthful and treat the patient with the dignity and the respect they deserve; Patient…..with a capital “P”.

With regard to the Wait Time Strategy, we are receiving conflicting information. Both Mr. Smitherman and Mr. McGuinty seem to want to dismiss the voices from the front line providers that are indicating the WTS needs a second look.

The Toronto Star from Feb.13, 2007 reports that Premier Dalton McGuinty admitted recently that his government was hearing lots of stories that its strategy was compromising wait times in other areas, but dismissed them as anecdotal "with a capital A."

This epitomizes what is wrong with a health care transformation agenda that pushes patients who don’t fit the grand scheme to the fringe, to become “anecdotes”, and which attempts to ignore the voices of providers who are working for their patients to get them the best care possible.

Who amongst us wants to be treated as an “anecdote”? Which patient wants their medical journey to be treated as an “anecdote” with the implied message that their problems aren’t real and are inconsequential?

A recent survey of surgeons across Ontario, conducted by the OMA, has prompted calls by Ontario doctors to measure the wait times for all surgeries and to measure a patient’s full wait time, including the time from when a patient visits their family doctor to when they receive the proper treatment.

The Toronto Star reported on Feb. 14, 2007 that:

While Smitherman dismissed the Ontario Medical Association survey of 640 surgeons as "questionable," he said the province will likely expand wait-time tracking beyond hip and knee replacements, cataract surgery, cancer surgery and MRI scans to see where patients are waiting the longest for care.

"That will give us a much better opportunity to direct funding in the appropriate way,"
Smitherman said. "But anybody who pretends we have the resource base to do everything at the same time is really just pretending.”

Also not mentioned are the wait times for many, many non-surgical treatments and even just a specialist appointment.

Even wait times in Emergency Rooms are reported to be missing the target.

http://www.nationalreviewofmedicine.com/images/issue/2007/feb15/4_length_stay_chart_3.html

 Smitherman announced he was putting the ED wait time targets announced in October on hold. "We're already having a difficult time," the minister said at a press conference. "Applying a standard that may in fact be artificial is not something that we have an interest in."

But it is something many patients have an interest in because their health and their lives depend on it in a country that denies individuals the right to pay for their own medically necessary care at home while attempting to sustain a system that appears to be developing cracks at a rapid rate. 

Almost a year ago,  I wrote in the Ottawa Citizen April 14, 2006 that:

“Care guarantees that cover only a few service areas are of no consolation to millions of Canadians whose medical needs fall outside these services. Wait times for many other areas exist, they just aren’t being measured.”

If we are to give patients the dignity and respect they deserve, then we must acknowledge that they are part of the solution and give them the freedoms required to help themselves.  

Wednesday
Feb072007

Cancer


There is plenty of discussion about prevention and screening tools when it comes to cancer. Some people even believe that prevention can lower the costs of our current health care system enough to sustain it.

Living healthy lives may give us more quality of life but eventually we will age. Some studies indicate we will have a 50% chance of getting cancer. This may seem high but considering the aging of our population and our ability to identify cancer, it doesn’t seem far off the mark.

If we survive, we can go on to needing other care including new hips and knees, new heart valves, new treatments for Alzheimer’s, diabetes, hypertension, other age related diseases not to mention long term care, and even more treatment related to complications from the cancer treatment itself.

Now don’t get me wrong. It is not that I don’t believe in prevention. I do. It is just that it is not likely to be the cost savings entity we are looking for. Dying would almost seem less costly for the system than prevention and all its related repetitive screening tests and associated treatment and care.

As more screening tools become available and more patients are screened, more cancers will be found, more will be treated, more patients will survive and more costs will be incurred. Instead of the cost being back-end loaded at the end of one’s life, the costs of screening and prevention will be borne potentially throughout one’s life starting in pregnancy and at birth with prenatal screening and neonatal screening. And of course, the cost of care at the end of one’s life will still mostly be to the “system” and will still be substantial.


Certainly, the solution cannot be to value the lives of the aged less. Many of us, hopefully, will reach old age and would very much like to have the same quality of care that would be given to someone of fewer years. Life is a bit finicky at times and quality of life is very much an individual perception.

With genomics developing to the point where “biomarkers” can identify which patients are at risk for which cancer (or genetic disease) because of their gene makeup and which drug should be used, or which vaccine would be of preventative benefit, we will face many more ethical dilemmas about how to ration health care resources.

It does not seem right that some patients, who have conceivably used the health care system very little over their lives, suddenly find themselves having to pay for their own treatment in our “universal, equal access” health care system.

In Ontario, new private ways of accessing chemotherapy are emerging such as the Provis Infusion Clinic for patients who have been left out in the cold.( http://www.provis.ca/provisindex.htm )


The Cancer Advocacy Coalition of Canada, recently reported that cancer patients are increasingly having to pay out of pocket for new important drugs and this “self-pay” trend is spreading. “Essentially, we will continue to ration life-saving cancer treatment, and some Canadians will live and some will die simply because of where they live,” says the report.

The Coalition suggests setting up a national “catastrophic drug costs” program so that all Canadians have similar access to proven cancer drugs. But Tom Blackwell writes in the National Post Tuesday, February 6, 2007: “The group acknowledges that governments in the future will not be able to pick up the entire cost of high-priced new treatments and urge people to purchase drug insurance when they are young.”

Prevention and screening methods with their related investigation and potential treatments will be part of cancer management. Cancer itself may become a chronic disease.

People who had no options before are being given options with new treatments such as radiation with multi million dollar machines using image guided radiation by combining CT scans and PET scans. See Varian Medical Systems Inc..

According to Dr. Yoshiya Yamada, a radiation oncologist at Memorial Sloan-Kettering Cancer Center in New York: “ We used to consider metastatic cancer incurable, so what was the point of taking aggressive treatment that would lower the quality of the remainder of the person’s life?”.

But now improved radiation therapies have improved five-year survival rates for cancer patients from 40% to 65% over the past 30 years and which could go as high as 80% as technology keeps improving. He says, “We’re giving options to people that had no options.”

The tide of treatment available will be beneficial to many but it will be necessary to understand how this can be funded given the constraints of our Canadian system. Restricting pharmaceutical company profit is not the answer either. The cost of bringing a new drug to market is close to the billion-dollar(US) mark according to Regina Herzlinger of Harvard Business School and the era of "personalized medicine" is upon us.


I believe our system needs to change to accommodate these new technologies and treatments and I don’t believe that our tax based system will be sufficient. New private methods of funding for other health care needs must be found and patients must have the freedom to access the life-saving care that they feel they need in the public system or in a private system if they feel the personal need.


Genomics, proteomics, pharmaco-genomics and technology are sharing a seat with cancer and taking up more room on the health care bus.  Tommy Douglas could not have known.


http://www.genomecanada.ca/xpublic/health/index.asp

http://www.canceradvocacy.ca/reportcard/2006/highlight4.html