Julia Belluz is an associate editor at the Medical Post and a regular contributor to Macleans.ca, where she writes Science-ish, a weekly fact-checking blog on health and health care policy. Follow Julia on Twitter @juliaoftoronto
For the first time ever, the Canadian Medical Association’s annual general-council meeting — known as the parliament of medicine in this country — is taking place in the Northwest Territories, land of the midnight sun, a large aboriginal population, and great holes in access to health care. The meeting is happening in Yellowknife because the CMA roams the country and gathers in the hometown of its new president, in this case, Dr. Anna Reid, a local emergency physician and an advocate of health equality.
There’s no conference hall large enough for the 400-some doctors and health-policy wonks who have descended on the subarctic capital, so they will convene in the gym of a local high school. Before the meeting, Dr. Reid spoke to Maclean’s about her view of the health system in this country and her year ahead.
You recently had a brush with the patient side of the health system through the loss of your mom. How did that experience impact your ideas about health care here?
Because our health system is delivered provincially, even though money comes from the federal government, the federal government has not put any accountability measures or parameters about how the money gets spent. So my personal story is that my father has Alzheimer’s, and my mother — who was his caregiver — died recently. My father is unable to receive long-term care services outside of Ontario, where he’s been resident his whole adult life, without huge long waiting lists. In Yukon, the waiting list is a year. In Northwest Territories, it’s six months for him to even be able to purchase services to live in a home, let alone receive them through the government. As a result, one of our family members actually has to relocate to Ontario.
What’s the solution then? Is this about having more federal involvement in areas of health care that have been the jurisdiction of the provinces?
Well — myself and also the CMA — we’d like to see some way across the country we can share best practices jurisdiction to jurisdiction. Because the Canada Health Act is limited to covering hospital and physician services, things such as long-term care, continuing care, and pharmaceutical coverage are not covered at all under the Canada Health Act, and there’s actually no portability of any of those services, so it’s completely up to each jurisdiction whether it decides to even fund those services. This means there’s huge inequality around the country about how one accesses these services, and it’s purely dependent on where you live.
How does this play out in your work here in Yellowknife?
It’s very difficult for low-income people to actually adequately access a lot of (health-care) services. They don’t necessarily have access to the educational resources, to computers, that allow them to look online to find resources. There’s poor access to housing, and people are unable to even have a phone so they can be available to make appointments. There’s no way to be contacted for test results. That’s a problem we see in our homeless population here.
Can you give me an example?
We’ve had people come in, get a chest x-ray done in the ER because we think they have pneumonia, then it looks like it’s not, so they are treated and sent back out to the street. A radiologist, several days later, reviews the report and finds a nodule in the lung that might be an early cancer. We have to get them back in, but have no way of contacting them because they are homeless. So often, we’re on a huge hunt around town, trying to phone every shelter, trying to get people to call in. Even that access to a follow-up is very difficult for disadvantaged people.
As a doctor who has practiced in several parts of the country — you studied medicine in Ontario, and worked in B.C. and the Northwest Territories. Is there a practice or payment model you favour?
In some areas, there’s no doubt that salaried arrangements are good models of care. For example, if you’re an emergency physician in downtown Vancouver, where there’s probably a large majority of the population that does not have any health-care coverage because they are homeless, if you’re giving doctors fee-for-service [where they are paid for each service they provide], they wouldn’t receive any income. But I was a fee-for-service family physician for years and that model worked very well. Sometimes there’s increased productivity with fee-for-service because more work is rewarded. But that doesn’t always mean better patient care. Like many things in healthcare, there’s not one thing that works. What we need to do is have a coordinated approach to looking at what our health human resource needs are, then local solutions in each province.
You’ve said doctors are “deeply demoralized” these days. What’s going on?
Physicians have been in some ways demoralized for quite a number of years. It’s been going on for several decades now that physicians are cut out of the decision-making process. They’ve been taken off hospital boards, they are unable to participate in meaningful ways in medical administration. This has been a well thought out approach by many governments and health authorities across the country. The minute you lose that sense of autonomy and empowerment, you get demoralized. With the [fee deal dispute between the Ontario Medical Association and the provincial government], what physicians were most upset about is that they’ve been left out of the planning. I think that’s what makes them upset: not the amount of money they are getting but that they are not part of the discussion of how decisions are made.
Still, some say doctors do have an extremely powerful voice in health care and that their self interest can stand in the way of health-care transformation and the move to more interprofessional health care. What’s your view?
I’ve been practicing since 1988 now and I would say over the last 10 years there has been a huge change in attitudes amongst physicians. We are working more as a team with other health-care professionals. I work in an ER. It’s a team. The nurse and everybody else is a team. We talk about each case, we manage cases as a team, there’s a mutual respect there that each person has a big role to play. So my sense is that this has improved over the years. A couple of decades before I graduated, the physicians in the hospital were served a lunch by the hospital kitchen with cutlery and plates. Physicians were gods. It’s not like that anymore. Everybody’s working together, scrambling to find a minute to get to the cafeteria. It’s not what it was 50 years ago.
One area that needs more coordination, it seems, is health human-resource planning. Right now, we have underemployed specialists in some areas, shortages of other kinds of doctors in other parts of Canada. Will you be working on this issue?
We are interested in looking at how we might have a co-ordinated federal approach that involves all of the provincial governments and medical associations in health human-resource allocation. So, how do we decide how many people need to be trained in each specialty? As you can appreciate, it’s an extremely complex issue, trying to predict what we need in the future. Practice patterns change, technology can make things faster so we may not need as many specialists in a certain area. But the CMA is interested in things that require a national, co-ordinated approach.
Is that your focus for your presidency: more co-ordination among the provinces and with the federal government on a number of health issues?
I think the key health issue is going to be the continued co-operation amongst the provincial health ministers and premiers along with groups such as the CMA and Canadian Nurses Association, in planning toward an integrated health-care delivery system across the country. That’s going to be the key health message that’s coming out next year. We would invite the federal government to play a more active role in that. We’re certainly very excited about what we’ve accomplished so far. Imagine if the federal government came to that table, what a strong force that could be.