Greener Grass

"Canadians don't realize how lucky they are" - US med student

Public funding, more family docs make Canadian health care system run better

By: Dr. Gordon Guyatt

  HAMILTON, ON: Jay Schuur, a medical student from New York University in New York city, came to Canada to learn to use the published medical literature to solve patient care problems. McMaster's international reputation in what is called "evidence-based medicine" drew him to Hamilton to spend the month of February on an internal medical ward.
  During his four-week elective, Jay worked with other physicians in training as part of an internal medicine team looking after patients with conditions such as heart failure, pneumonia, stroke, and cancer. At any one time, Jay was responsible for the care of three to five patients. He assessed their problems, planned investigations and treatment, and arranged for their discharge and follow-up. The specialist in internal medicine in charge of the team would review the patients with him, revising his diagnoses and plans as necessary.
  Jay proved intelligent and industrious, and by the end of the month he was skilled in interpreting diagnostic tests, and choosing treatments, on the basis of original research published in medical journals. He had also developed his impressions of medicine in Canada, in comparison to his experiences in New York City.
  Perhaps Jay's biggest surprise was the quality of the primary health care system he found in Hamilton. As each patient was ready for discharge home, one of Jay's jobs was to contact the patient's family doctor. Jay would explain the patient's course in hospital, and what was necessary for the patient's subsequent care.

In the US, the uninsured avoid doctors until they face a crisis they can't ignore, then present to a hospital ER

More Canadians than Americans have family doctors
  Jay was surprised to find that all of the 15 or so patients he shepherded through to hospital discharge had a family doctor they had visited regularly. His experience was very different at home in New York. Across the United States, 15 percent of the population do not have any medical insurance, and the proportion of uninsured is even higher in New York City.
  Most of the uninsured cannot afford regular visits to a family doctor. Chronic medical problems such as high blood pressure or diabetes are usually neglected. The uninsured avoid doctors until they face a crisis they cannot ignore, and then present to a hospital emergency department.
  Jay was surprised to find not only that each McMaster patient had a longstanding relationship with a family doctor, but that the family doctors were ready to see their patients promptly after discharge. As the number of hospital beds in Canada has contracted, and hospital stays have grown shorter, such ready access has become increasingly important.
  Consider, for instance, a patient who needs medication, so-called "blood thinners" or "anticoagulants", to prevent blood clots that could lead to a stroke. Not enough blood thinner risks a clot; too much can cause bleeding. In years past, the patient stayed in hospital for the fine-tuning of anticoagulant dose.
  In 2001, patients are often discharged earlier, and the family doctor takes care of establishing the right dose of the blood thinner. This new pattern of care is much more efficient. Stable patients waiting in hospital while doctors adjust their anticoagulant dose is not the best use of a hospital bed. However, to work well, it requires conscientious and rapidly available care from the family doctor.
  Jay found working at the McMaster division of the Hamilton Health Sciences Corporation, he could take such care for granted. Back home in New York, he could not make the same assumptions, particularly for the uninsured.

HMOs reduce doctor access for Americans
  Making matters worse, much of American care is now dominated by large, for-profit Health Maintenance Organizations or HMOs. There, in response to industry productivity standards, doctors typically see large numbers of patients in the course of a day. This industrial model means that the doctor spend only a few minutes with each patient.
  To ensure their productivity, doctors will be fully booked, and cannot easily accommodate patients on short notice. The strategy is good for corporate profits, but not so good for optimal patient care.
  Jay did not see at McMaster the increasing stresses in Ontario's system of primary health care delivery, however. While Hamilton patients still find family doctors with relative ease, most practices are full, and the search is more difficult than in the past. In some communities, finding a family doctor may be next to impossible.
  While the physician access problem is real, only political will is required for a rapid solution. An increasing use of primary care nurse practitioners may represent the best of a number of possible remedies.
  Watching the stresses in the Canadian health care system, it is easy to forget that every industrialized country is facing the same challenges, and the Canadian system is coping better than most. We do need provincial and federal governments to make a renewed investment in health care, and to implement innovative strategies such as wider use of nurse practitioners. At the same time, we would be wise to remember Jay Schuur's bottom line after spending a month in a Canadian hospital.
  "When it comes to a health care system," Jay told me, "Canadians don't realize how lucky they are."

Dr. Guyatt is a founding member of the Medical Reform Group, and an MRG spokesperson for most of the last 20 years. He is a Professor of Medicine at McMaster University. A version of this article appeared previously in Hamilton Spectator.

Posted: April 09, 2001

[ Front Page ]