Health care and research in Canada, 1978. Part I JACQUES GENEST, CC, MD, LL D, D SC, FACP, FRCP[C], FRSC

In 1956, I was amongst the first physicians in Canada to promote the concept of a national, comprehensive program of hospital insurance.1 The reason that at that time I strongly emphasized the necessity of a universal hospital insurance system, in contrast to a full medicare system, was the increasing financial burden of hospital care for the individual patient. I also emphasized, as the Canadian Medical Association had done so often throughout the years, the importance of the prevention of disease by improvement in the environment, in nutrition, housing and work conditions. It is comforting that these objectives, so repeatedly stressed by the Canadian Medical Association and other bodies,2'3 were finally officially endorsed by Marc Lalonde, former minister of national health and welfare, in his publication "A new perspective on the health of Canadians". It is heartwarming that at last our governments have become more conscious of their responsibilities in this field. Promotion of health, whether by the prevention of disease or the cure of sickness, has always been a major preoccupation of mankind. This was well expressed by Senator Maurice Lamontagne, chairman of the Senate inquiry into science in Canada in an address Oct. 17, 1971, to Medical Research Council scholars at Ste. Marguerite, Quebec: If we agree that relevance to human welfare and the values of man has a high priority, then we must recognize that medical research together with its related scientific and technological fields belong to the top of the list of our scientific choices because numerous surveys show that people attach great importance to health problems and want within certain limits the best possible health care system. in our democratic regime, we must accept this public preference as a major goal. (Italics are mine). Reprint requests to: Dr. Jacques Genest, Scientific Director, Clinical Research Institute of Montreal, 110 Avenue des Pins, Montr6al, PQ H2W 1R7 Dr. Genest's article is based on the William D. Scully lecture, which he delivered in Hamilton earlier this year.

In an October 1977 survey by the Canadian Institute of Public Opinion4 88% of those interviewed said the Canadian public is receiving good value in the medical services provided by our government. This ratio varied from 84% in Quebec to 93% in British Columbia. This widespread satisfaction of the Canadian public is without doubt due primarily to the fact that the chief objective of medicare in Canada has been achieved the universal availability of all types of medical care at no direct cost to the individual. It is also due in large part to the medical profession which, under the leadership of the Royal College of Physicians and Surgeons of Canada, the Canadian Medical Association, the deans and members of the medical faculties, has rallied to reform itself and to accept and adapt to the changes found necessary in the evolution of our Canadian society. There is no question that members of the medical profession have tried hard despite many administrative difficulties and frustrations to give the best medical care possible to their patients. It is of interest to compare this Canadian survey to a more recent one of the University of Chicago on health care in the United States. Although 88% were satisfied with the care received, 61 % of the respondents said there was "a crisis in health 5 care Fragile situation Cheering as such survey results are with regard to our medicare system, those of us involved in the distribution of health care and the care of patients must seriously doubt whether those interviewed could judge whether the quality of medical care they were receiving was adequate or was improving or deteriorating. On the contrary, the present situation is fragile. There are alarming signs of rapidly increasing depersonalization and dehumanization,6 which need quick corrective measures if we do not want to see a severe deterioration of the quality of health care in Canada and if we do not want the same type of mediocre medical care as

that given under dictatorial socialist regimes. It has been easy to adopt laws and regulations to establish a universal medicare system, but the translation of its objectives into reality has resulted in many instances in a mess, partly because those in charge of implementing the laws and regulations lack knowledge of health care and systematically reject input from the medical profession. The medical profession has gone through a painful period of soul searching following the many criticisms directed against it. It has not yet recovered the leadership society expects from it, which is essential if the public is to receive medical care of the highest scientific standards combined with compassion and understanding. The efforts of the medical profession to provide an enlightened input into the policies, regulations and implementations of political and bureaucratic decisions have been systematically ignored or rejected, as was the case in Quebec by Claude Castonguay and his subordinates.7'8 The medical profession has become so tired of continuously fighting inadequate, if not at times absurd, decisions that many of its members have become deeply irritated or resigned to passive resistance and doing their best under most difficult circumstances. As a result, motivation and devotion to patient care have been rapidly eroded. Many physicians, often in key positions, have unfortunately lost all combativeness and have simply given up. The members of the medical profession feel that they have been relegated to the function of bureaucratic providers of health care, cast in the role simply of purveyors of diagnoses and prescribers of pills or surgery! The medical profession has had to tolerate that in Quebec a 10% minimum of all hospital beds are directed to be reserved for chronically sick, poststroke or senile patients (in reality, this proportion varies between 10% and 30%). The University of Montreal Hotel-Dieu Hospital, at the beginning of February 1978, had 119 chronic cases waiting for transfer, that is 20% of a total 571 beds. In

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the 206-bed department of medicine, there were 101 chronic cases, or 49%. When I took over the nephrology service as visiting physician in that month, 70% of patients were chronic or senile ones for whom transfer had been requested, in all cases several months previously. Such patients require only cleaning and feeding by auxiliary nurses or untrained personnel. The average cost per patient in our hospital is at present $285/d. In December 1977 in five university affiliated hospitals in Montreal 40% of patients in active beds assigned to the department of medicine were "chronic" or senile. Apart from this scandalous waste, how under these circumstances, can a teaching hospital perform its functions as a referral centre and an institution for teaching medical students, interns and residents? How can it have the necessary material for clinical research? When told that such an intolerable situation was ridiculous and wasteful, a highly placed civil servant in Quebec answered that if such patients were taken out of the teaching hospitals, the government would have to spend more to build homes for such patients and the hospital beds so freed would immediately be taken up by more acute cases. Let me just give you the example of a 93-year-old labourer admitted to the Hotel-Dieu Hospital June 1, 1971 suffering generalized atherosclerosis and gangrene of the right foot, which was amputated. A request for transfer into an old people's home was made at the end of June 1971 and the transfer was made Oct. 3, 1973. This patient, therefore, spent 27 months in a teaching medical centre at an average per diem cost of $250 - a total cost of over $200 000. There are thousands of such cases in our hospitals. No one protests this enormous waste of public money except the doctors, who are never listened to, and those in training for geriatrics. Because of Castonguay's decision to give equal pay for so-called "equal" service,9 there is no reward or consideration for experience, expertise, motivation and devotion to the patient. An honorarium of $7 is allowed for a home visit, with the result that these have almost completely ceased, and emergency rooms

built for the needs of the 1 930s are today so congested as to look like cattle barns, with patients lined up on stretchers on both sides of corridors. The distrust of the medical profession is well illustrated by the virtual absence of physicians in the higher echelons of the medicare system. Those who are present are completely outnumbered and outvoted by other bureaucrats, who are in full control and who share the conviction that doctors' only interests are financial and they cannot be trusted to act for the public good. It is therefore not surprising if there are unenlightened leadership, poor planning, continual hesitation in decision making and self protectory attitudes at the higher levels of the medicare bureaucracy. The medical profession must take its share of blame in having to some extent lost control over the advances in technology proposed for the management of sick people. This is notably evident in the intensive care units, in which no postoperative coronary patient is considered adequately taken care of if tubes are not installed in the stomach, bladder, at least one artery and several veins, and if the patient is not monitored by electronic gadgetry. Dilemmas Modern medicine faces severe dilemmas.10 It must defend the interests of the public and the medical profession against a huge, anonymous bureaucracy that is often ignorant of the complex realities of health care and yet is so overwhelmingly powerful. The doctors face the dilemma of progressive automation of health care

abdication of many members of the medical profession and their subsequent loss of motivation (as observed in all dictatorial socialist countries) is seen in the abuse of medical certificates, which are often given for extended and unnecessary periods of convalescence and for trivial reasons. In common with the rest of society and with the pervasive materialism and search for instant comfort, the medical profession has also become increasingly bourgeois in its attitudes. This has resulted in a severe decrease in societal participation and community service. The doctors have organized themselves into societies and federations, which in fact are more unions to protect interests and privileges than they are "learned societies". Advances in technology, together with the many committees that investigate or certify the quality of care given to patients, have resulted in greater anxiety in doctors, and the result is a multiplication of unnecessary laboratory tests and radiological examinations. Too often the results of such tests and x-rays have become more important for the doctor than a carefully taken history and physical examination. It is not surprising therefore, that medical diagnosis and management are governed so often more by the doctors' anxiety than by the exercise of clinical skills. Now let us consider the control exercised by elected representatives and government officials. After 8 to 10 years of medicare in Canada, all aspects of health care except those of diagnosis, prescribing and treatment have come under the almost complete control of politicians and government officials, who may have some knowledge of the socioeconomic aspects, but almost no expertise in the complex field of health care realities. The most serious weakness has been restriction of physicians to diagnosis and treatment. The exclusion of medical experts from the planning, decision-making and implementation processes of health care organization has resulted in innumerable faux-pas,t which have

through computerized history taking and automated laboratory tests and even management of patients versus traditional care through a personal doctor-patient relationship. Since the economists and sociologists have decreed that health care is an industry and have made costeffectiveness (or cost-benefit) the major consideration in the organization and distribution of medical care, the castonguette* has quietly dis- tThese events confirm completely many placed, to an important degree, the criticisms which John Beck and I made essential factors of understanding, in 1967 and 1968 concerning many feaof the Castonguay Report on Health compassion and motivation so im- tures Care,11'1' features which were often naive portant for the quality of care. The when not distrustful of the medical pro-

*Govemment billing form named after former Quebec minister of social affairs.

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fession and ignorant of the realities of health care.

contributed heavily to the present profound irritation of all doctors and the laissez-faire resignation of too many. The neglect or rejection of almost all proposals made officially by the medical profession to Claude Castonguay when he was minister of social affairs were carefully documented in December 1972 by the Professional Corporation of Physicians of Quebec. This was readily confirmed13 by the new minister, who said: "I am disturbed that since 1970 when many of the present health reforms came into being, doctors have been absent from the health planning stages of the Ministry of Social Affairs... Expanding bureaucracy

The implementation of medicare has resulted in a huge, anonymous bureaucracy strongly criticized by Laval political scientist Leon Dion.'4 Bureaucrats have proliferated according to Parkinson's Law; they have no direct responsibility to the public and are too often insensitive to patient needs. There are widespread complaints that many civil servants have remained very civil, but (especially in the higher echelons) no longer the servants of the people; they have become the servants of their own expanding power and control over public affairs and health care. The powers of top government officials and their control of the purse have led to undue influence over the whole field of medicare - the medical schools, hospitals, research centres and even medical practice and it is common knowledge, unfortunately, that criticism of the decisions or policies of these civil servants can bring swift, effective retaliation. They have ways of bringing "erring" doctors, hospital directors or others under effective control and silencing their opposition by blocking or indefinitely delaying requests for equipment, increased salaries or other improvements, by not answering letters, not returning phone calls and not even acknowledging telegrams. Another elegant method is the merry-go-round, in which one is sent from one office to another or to a different ministry and back again. Nor can pressure be usefully kept up by going to higher levels such as the minister or even the prime minister. In my own personal

experience, powerful bureaucrats render even a prime minister's decision inoperative by skilful delaying tactics and further merry-go-round treatment. Such tactics can effectively stifle all public criticisms by key doctors of government policies and decisions. Dr. Gustave Gingras, a former CMA president who is world-famous for his work in rehabilitation, has repeatedly pointed out the lack of facilities for paraplegic patients. "I have written memos, I have sent dossiers, letters, statistics and reports to the Ministry of Social Affairs in Quebec City, outlining the problem, but I don't seem to be getting anywhere," he has said.15 We have a unique situation in Canada (I believe in the world) whereby interns in our hospitals who are paid about $13 000 a year can, in the first year after they receive their licences to practise, make incomes of $40 000 to $70 000. This arrangement was made expressly to attract young doctors into family or community practice. It has proved irresistible: two-thirds of young graduates go into family practice. This leaves only a minority for the various specialties and virtually none for the insufficiently remunerated, insecure fields of biomedical research and medical education. I doubt strongly that with only 1 year of hospital internship for the majority of general practitioners, the public will receive the quality of medical care that it wants and that it deserves. But for the economists, the sociologists, the politicians and the bureaucrats, one doctor is the same as another, irrespective of training, experience and moral qualities of compassion and dedication. Another example of a poor decision was based on the conviction expressed by Mr. Castonguay9 and others that the medical profession had rigged admission into Canadian medical schools to artificially limit the number of health professionals. Therefore, under direct threats and near-blackmail from provincial governments, medical schools have been forced to enlarge even to the point of almost doubling the number of medical students. Laval medical school was obliged to expand from an average of 130 students per year before 1970 to an average of 182 in 1973-74; McGill, from 75 stu-

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dents per year to about 170 in 197576; University of Montreal, from an average of 125 to an average of 205 in 1975-76; Sherbrooke University, from an average of 48 to an average of 108 in 1975-76... These imposed increases were not accompanied by similar increases in material facilities or numbers of teachers. In addition, Canada's doors were wide open for immigrant doctors. But barely 7 years later, these same "planners" who felt so sure of their findings have closed the door to doctors from other countries and, as in Quebec, have imposed a quota on the number of residents and internship posts paid by government, decreasing them by almost 30% in 1980.17 Those interns or residents not selected can still go into training, but only on an unpaid basis. This will force an even greater number of interns to go directly into general practice. Is this really the quality of medical care that the public wants or deserves? The freedom of the individual to choose his doctor or hospital has been curtailed in at least two respects: first, public ambulance services are instructed, to take patients only to the designated hospital of their zone; second, a patient coming into the emergency room of a hospital is denied the privilege of seeing his own doctor and is told he has to be taken care of by the doctor on call that day. I know of many specific examples. The main objective of providing universal health insurance at no direct cost to the patient has indeed been attained, but the other objectives of providing high-quality health care and making it continuously accessible, especially in distant localities, are far from attainment; there are in fact serious reasons to believe that there has been no change or even that we have gone backward in this respect. As one doctor friend of mine remarked: "Before medicare, 50% of the population was receiving 100% of the care and now 100% of the patients are receiving 50% of the care... Political arrogance The arrogance, even insolence, of

some politicians goes to the point of continued on page 532

our society. Areas of stress and conflict find ready expression in direct and fresh projections in spontaneous art by children. In telling stories that are stimulated by his artistic projections, the child can give immense help to the adults trying to understand his predicaments." Dr. Fischer's institute has set up "spontaneous art programs" in several schools in the Toronto area, in which disturbed children are given the opportunity to express, in a safe environment and medium, feelings that might otherwise lead to withdrawal or aggression. Dr. Fischer considers that the "considerable disinterest" in art therapy which he so deplores is not just narrow-minded; it is also short-sighted. "Twenty per-

cent of the children in our school system are emotionally disturbed. I believe that 80% of these could be helped within the school, through a variety of therapies, without the expensive institutional care that is so often the only solution nowadays." So far there have been 11 graduates from the Toronto institute, who have been awarded the institute's private diploma and are now facing the awesome task of persuading school heads that art therapy is valuable enough to warrant loosening the purse strings for. After talking to the various individuals active in the art therapy field, I came away impressed by the efforts of individuals and convinced that for those people who are failed by words, producing pictures can be therapeutic in itself, a valuable projective technique and a conduit to the external world. But I was not

convinced that it held a monopoly on any of these benefits, as some of its more vehement defenders appear to claim. In the ideal world of limitless budgets, an art therapist in every psychiatric and educational institution would be a wonderful asset. But as Dr. Lowy from the Clarke said, "We have to allocate our resources according to needs, and we have other modes of recreation, expression and diagnosis." Currently, the only way an art therapist, whether trained or not, is likely to be employed is if the head of an institution has a personal conviction that the therapy is of value. This means small pickings for the graduates of Dr. Fischer's and the various US training institutes and aspiring therapists who have no training - but it also means that the therapist is warmly welcomed into the kind of setting where his or her work can probably be most useful.*

RESEARCH continued Irom page 506 chastizing the Professional Corporation of Physicians of Quebec over a recommendation to establish an intensive care unit in a regional hospital after a site visit by experts. In a letter to the president of the corporation published in the corporation's Bulletin, August 1976, the then minister of social affairs challenged directly the value of ICUs for survival of patients. He also challenged the right of the corporation to make recommendations for the improvement of regional services.

The distrust by government officials of members of the health professions extends to new buildings. Such construction is under the complete control of government officials, from the contracts with architects, engineering firms and builders to supply of materials. Contracts are drawn up by civil servants. Tenders have to be obtained by the hospital and health centre from three sources and submitted to the ministry for approval. Payment for services already rendered has to be resubmitted for approval. This control extends even to the design of laboratories and choice of materials for working

benches and tables, even size and colour of drapes. Amid such frustrations, I remember the bawling out I gave to a so-called expert who came with an earring in his left ear and wanted to force us to use 16 mm formica sheets for our laboratory benches. His only previous experience was that of a small laboratory in a high school. This distrust and total lack of confidence is most oppressive, if not profoundly insulting. A full list of references will be published at the end of Part II of Dr. Genest's article, which will appear in CMAJ Sept. 23.

has happened or what time of the day it is, I don't have to act totally continued from page 528 detached and professional." For Dr. Jerry Green, Willowdale tionist to Dr. Bruce Stewart, a To- nutritional specialist, it was the secronto neurologist, observed: "We ond time he'd attended the course, don't have as many patients as gen- the first being when it was given in eral practices do; nevertheless some the single-day session last year. He of the principles are the same. felt that the same information was covered in the expanded session. Dr. "I left with the thought that I had Green thinks the principles covered to have a more friendly attitude to- in all the sessions are relevant since ward the patients. No matter what most doctors typically are abysmal

businessmen! But he says they're tough to get through to because they are tremendously resistant to new ideas - whether proposed by management analysts or nutritionists. The key point for a physician to remember, says Landry, is that he's the boss, he is running his own practice and he should be at the helm. Physicians tend to react too much to the environment. The system must react to them. Then they can be in complete control. U

ART THERAPY continued from page 497

SEMINARS

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References

Health care and research in Canada, 1978. Part II.

Health care and research in Canada, 1978. Part I JACQUES GENEST, CC, MD, LL D, D SC, FACP, FRCP[C], FRSC In 1956, I was amongst the first physicians...
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