By Henry Gray (AIMS on Campus Student Fellow)
Since Hippocrates’ Oath, the Western world has understood the underpinnings of healthcare to be rooted in a fundamental, fiduciary bond of trust. Yet present Canadian policy does little to promote this bond. For many Canadians, this strong fiduciary relationship is not a reality. This problem is particularly acute in Atlantic Canada. In comparison to the rest of the country, the Atlantic Provinces have higher numbers of residents on waitlists for family physicians. This leaves many seniors without a dedicated advocate as they face higher rates of chronic illness, unique health challenges, and desperate lack of mental health services. In Nova Scotia, for instance, a 2017 report by Doctors Nova Scotia lamented that more than half of the 235 physicians they surveyed felt unable to properly care for their patients. The report identified five key issues contributing to this shortfall: (1) fragility of the physician workforce, (2) loss of professional autonomy and satisfaction, (3) erosion of comprehensive family medicine, (4) unsustainable rural specialty services, and (5) lost opportunities to leverage technology. The report claims that these challenges stem from a lack of trust that once existed between “physicians and key health-system stakeholders.”
It is a cliché that Canadian healthcare is “free,” and we “get what we pay for.” But, of course, Canadians pay quite a lot in taxes for the privilege of enjoying our universal-access health care system, which is close to being the most expensive of its kind in the developed world. Despite the steep price of admission, our system ranks near-to-last in most assessments of timeliness of care. Canadians who take ill can look forward to long wait-times in the emergency room and longer wait-times for specialized services. Due to the unavailability of family physicians, patients often have no choice but to visit the emergency room for conditions that regular doctors could treat. Further, government-imposed fee schedules prevent physicians from making their patients’ care more accessible, while bureaucratic red tape stands in the way of facilitating physician-patient communication thus impeding the potential for integral physician-patient relationships.
Atlantic Canadians living in rural areas have an even harder time getting access to healthcare. According to Dr. Michael Teehan, head and clinical chief of Dalhousie University’s psychiatry department, it is much more difficult to access mental health services in rural settings, “although the people who are practicing are as well-trained as anybody in the city. They’re just stretched beyond capacity.” At root, what we have in Atlantic Canada is a problem of supply and demand. Physicians in rural areas are struggling with the costs associated with maintaining a practice, which are rising while fees remain stable, and are experiencing burnout as their patient roll increases and they struggle to meet needs that exceed their individual capacity. This is coupled with their awareness that while they have entered their profession to heal and provide care, they are living with the reality that many people in their community are going without.
The current model is unsustainable. If nothing changes, physicians will continue to burn out or be unable to maintain their practice for financial reasons, and Atlantic Canada, especially her rural areas, will continue to lack adequate and timely services.
What are some possible improvements that could be made?
A growing number of graduates of top-tier Canadian medical programs are being overlooked for residency positions. Readers may recall the tragic story of Robert Chu, a medical school graduate who took his own life on September 5, 2016, after being passed over twice for medical residency programs. On the one hand, there is a desperate lack of healthcare providers in rural Canadian provinces, and, on the other hand, we have a system that devotes hundreds of thousands of provincial government dollars into educating and training future doctors, only to inform them that there are not enough residency positions for all of them. And this is certainly not for lack of need in communities across Canada. A major step in improving access to healthcare in rural areas would be to increase residency spots, and, ideally, to require a rotation in rural locations as part of the process and training.
Secondly, provincial governments should adopt policies that improve the fiduciary bond between doctor and patient, while empowering patient autonomy with the use of modern technology. This can be accomplished through an increased focus on rural health training and education. It can be facilitated through improvements to ‘telehealth’ services that would allow Canadians access to their own health information, reducing the need for in-person visits and keeping accurate measures of the results of care. Physicians in rural areas should be given a voice in the selection of such health information systems.
Finally, Canada should follow the lead of other countries with universal healthcare systems and healthcare spending at levels comparable to or even lower than ours that have shorter wait times and similar or better outcomes. Successful universal healthcare systems in countries such as Australia, France, Germany, the Netherlands, Sweden, and Switzerland – most of which rank significantly higher than Canada overall, on quality of care, access, efficiency, equity, and healthy lives according to The Commonwealth Fund’s 2014 report – have incorporated simultaneous, supplementary and complementary private for-profit or not-for-profit hospitals and insurers into their policy framework. The examples of these countries offer conclusive evidence that private-sector healthcare is eminently compatible with universal-access healthcare. The fact that we continue to see shortages and lack of access to healthcare in Canada despite high spending suggests that it is time to look for alternatives. Why not see whether some policies being implemented in developed countries around the world can be of use in Canada? Private-sector care could have tremendous upside for the debt-ridden Atlantic Provinces, and it could also improve doctor-patient trust and increase accessibility to health services.