Patient Accountability II

In January, I wrote a brief introductory essay on the reasons I feel patients must be included as full partners in health care, having not just the right to good care, but also responsibility for certain facets of the health care system.  There were so many comments and concerns raised by that introduction that I felt it was important to follow up with a bit more information to think about and clarification of why, in my view, patients need to be full partners in accountability.

One of the striking facts about the Canadian provincial health plans is that government documents and websites highlight patients’ rights and never mention patients’ responsibilities. I looked through the documents for each province and territory. Here are links from the British Columbia website and an Ontario government website for new immigrants as examples. I attempted to find a document for Ontario similar to the British Columbia Document, but this did not seem to exist, except for new Canadians. The document for new Canadians does list responsibilities but I was struck by the fact that the website also contains this phrase: “You are entitled to all of the patient rights that are described in Ontario laws, even if you do not follow these “responsibilities.”  The other document I have included is a Government of Canada comparative overview of patients’ bills of rights from around the world. Note once again that rights are noted without mentioning responsibilities.

Contrast this with the fact that other countries with a publicly funded system do list both patients’ rights and responsibilities. This is also true of many physician practice groups in Canada and hospitals. Both hospitals and physicians’ practices absorb the costs in their budgets if time or resources are not productive. In my hospital’s Youth Psychiatry program, missed appointments or late arrivals mean delays for another patient’s assessment or treatment. That’s why we have a rule that, if a patient misses more than two appointments without 24 hours’ notice, we close the file. Given that Ontario’s healthcare budget covers the cost of the therapy provided in the Youth Program, most patients and their families understand that missed appointments affect access to care and accept the rule.

The emphasis of patients’ rights, in the absence of a consideration of any responsibilities, makes physicians uneasy. It also makes many physicians, including me, feel as though the responsibility for stewardship of the system is not shared by patients.

All physicians have days when we feel as though every appointment consists of reviewing with patients that the tests they want are unnecessary and treatments they would like are proven to be ineffective. Physicians honestly want to follow best practices, and improve system efficiencies and these discussions with patients about necessity prove that. Physicians could have much less conflict in our days if we just agreed to order every blood test, consultation or x-ray that patients request. At the same time, every physician I know is very understanding when a person’s living conditions or financial situation make it impossible for them to follow the recommendations they’ve received for examinations or treatment.

One reader of my last Patient Accountability essay commented that defining patients’ responsibilities was a “slippery slope” to blaming patients for their health problems. My experience is that anything less than a full discussion of a patient’s history, examination and diagnosis, along with an outline of the best practices for further tests and treatment is a “slippery slope” to an old style of medicine in which the patient was expected to “do what the doctor ordered”. That kind of paternalism is no longer acceptable in medical practice. The standard of care today is to review the diagnosis and recommended tests and treatments thoroughly so that patients understand the options for further evaluation and treatment and consider with their doctor and other care providers what would best for them. Patients no longer want to be patronized by the doctors providing their care.

Canadians are aware that their much-celebrated health care system is not keeping up with demand and it would be a relief for most people to know that there was something they could do to preserve and improve their health care. We are all aware that many Canadians can no longer afford necessary medications, but we also realize as our national and provincial deficits increase that we cannot spend away the health care system.  Providing good care in the context of excellent information about best practices is what all doctors try to do. My experience with patients is that they want this information so that they can do whatever it takes to get well. How is that not taking responsibility? Why can governments in Canada not accept that this is the right thing to do?

Which Doctor Do You Want?

Last Saturday, May 2, 2015, Dr. Michael Toth was installed as the 134th President of the Ontario Medical Association (OMA). Mike is a comprehensive Family Physician from Aylmer, Ontario. Aylmer is a town of 7500 in Southwestern Ontario. He told the guests at his Installation Gala that his patients range in age from newborns to over 100 years old.

I got to know Mike as a Board member in 2009, just after his election as Physician Services Committee CoChair. Within a month of his election he resigned because one of the physicians at the Nursing Home where he is Medical Director could no longer work there and Mike was needed in Aylmer to look after his patients. That’s the kind of doctor and person that he is. To me, he was one of the most powerful people on the OMA Board, but his patients came first. His lesson stays with me and so I juggle my OMA responsibilities so that my roles as a wife, mother and doctor are not compromised. Just like Mike, or as much like Mike as I can be.

Consider now a second doctor, the Minister of Health and Long Term Care, Dr. Eric Hoskins. After completing medical school and residency, Dr. Hoskins worked as a humanitarian and a doctor in war-torn regions around the world. With his wife, Dr. Samantha Nutt, he founded War Child Canada, which seeks to help children in regions around the world affected by war. His work has influenced policy and has been far-reaching. He is an Officer of the Order of Canada. Now a Member of Provincial Parliament for St. Paul’s, a riding just outside Downtown Toronto, Dr. Hoskins must wrestle with the issues of health care at home in Ontario.

As a citizen and a doctor, I hope that Dr. Toth and Dr. Hoskins will have a productive relationship. The OMA and the Government of Ontario are currently disagreeing about how to manage physician services, but that shouldn’t stop the two doctors most visibly associated with those resources from being respectful and courteous with each other. Dare I say collegial? However, Minister Hoskins was noticeably absent from Dr. Toth’s Installation.

A lot of Past Presidents hang out at Presidential Installations and I was told that Minister Hoskins’ absence was unprecedented. I asked all the people who might know and no one could tell me the reason for the Minister’s absence. No Past President could ever remember the last time a Minster of Health did not attend the OMA President’s installation. In 2012, two days before the Government imposed fee cuts on doctors, Minister Deb Matthews took the stage at Dr. Doug Weir’s Installation and warmly wished him well.

The relationship between the Ontario Medical Association and the Ministry of Health and Long Term Care is broken for the second time in three years. “Our situation cries out for common sense,” Dr. Toth said in his address to OMA Council the day after his Installation. Mike Toth understands common sense. He also understands common courtesy. I was born in one small town and grew up in another. Believe me, if you don’t have common sense and common courtesy, you won’t manage with the neighbours, let alone your patients, who may represent one fifth of everyone in town.

I hope Minister Hoskins let Dr. Toth know personally why he couldn’t attend his Installation. Dr. Toth would understand as much as anyone if the Minister had other family or professional commitments. He would not have taken it personally that he was one of the only OMA Presidents whose installation was not attended by the Minister of Health – he’s not like that.

But this small town girl is still taken aback. I was born in an English-speaking town and grew up in a French-speaking town. In both official languages, I learned that common courtesy and common sense were as necessary as food and uncommon kindness and genuine respect were the currency that bought you a special place in the world.

I suspect Mike Toth is more forgiving of Minister Hoskins than I am. Once again, I will learn from him and remember that it’s absolutely necessary to curb my tongue and get on with the work at hand. But first, I’m going to say that my money is on the small town doctor being the person who can bring some common sense back to healthcare in Ontario.

It’s possible that living in the big city of Ottawa has addled my brain and loosened my tongue.

Canada’s Champion of the Arctic

Today in Kinuna, Sweden, Canada’s Minister of the Arctic Council, the Hon. Leona Aglukkaq, took over as Chair of that council. This recognition of Canada’s expertise, specifically symbolized by Aglukkaq, the first Inuk to be sworn into the Federal Cabinet, provides an opportunity to reflect on the reputation and accomplishments of this Minister.

Minister Leona Aglukkaq was sworn into Cabinet as Minister of Health in October 2008. She has faced a lot of criticism over the four and a half years she has spent in that portfolio. Some of the concerns raised about the federal governments’s management of healthcare under Aglukkaq included concerns about the recently changed medical marijuana policy and the decision in November 2008 not to block the release of generic oxycontin. I begin by mentioning these two initiatives because, if you scroll through previous articles on this website, you can read about my own concerns with respect to these policies. Another more recent action of the Haper government, the decision to stop funding the Health Council of Canada, was also roundly criticised by many groups. (Reference: http://www.huffingtonpost.ca/2013/04/17/health-council-canada-cut-leona-aglukkaq_n_3100123.html )

Having said all of this, it is obvious that Minister Aglukkaq has risen to a position of trust within the Harper cabinet. Prime Minister Harper is a strong supporter of Canada’s Arctic sovereignty. He appointed Aglukkaq Minister of the Arctic Council in August 2013, knowing full well she would become Chair, the first Inuk to chair this body. Strategically, how can you argue with this good sense?

Perhaps, then, it would behoove us to look more closely at the overall philosophy of the Harper government and Minister Aglukkaq with respect to the federal management of healthcare, in order to examine how better to work with them.

First of all, there is a commitment on the part of this federal government to costsharing in healthcare. The government has pledged a 6% transfer payment after 2014 for three years and 3% annually after that. While the “no strings attached” policy has bothered many Canadians and national health care organizations, might one not say that this allows the provinces, who actually administer healthcare, to plan ahead, considering the needs of their own citizens? This is a policy that is very much in keeping with the small “c” conservative ideal of “smaller government”. We might not all agree with this ideal, but can we deny from whence it comes?

Secondly, this government has commited to ending the Health Care Accord and with it, the Health Council of Canada, the federal agency established to administer it. Again, this is consistent with the wish of the government to decrease the size of governemnt and its costs.

Next, this is a government that has made significant investments in mental health. It established and continues to support and promote the Mental Health Commission of Canada. In January 2013, Canada’s Labour Minister, the Hon. Lisa Raitt,released Canada’s National Standard for Psychological Health and Safety in the Workplace. This standard is the first of its kind in the world, addressing the reality that mental health is and will be the most pressing health problem for workers in the 21st century. Can we not work with the Harper government to promote their vision to decrease the burden of mental illness? (Reference: https://drgailbeck.com/2013/01/26/standard-for-workplace-mental-health-and-federal-engagement/)

Minister Aglukkaq has weathered the criticisms of Canadians and healthcare organizations over almost five years as Minister of Health of Canada. As she quietly goes about the business of implementing the federal government’s plan for healthcare, we can often hear her speaking of her love for her home and her community, entrreating us to see beyond the challenges to what the North can bring to Canada. Minister Aglukkaq has broken the glass ceiling and burst out of the confines of the prejudices against Canada’s aboriginal peoples. Prime Minister Harper has entrusted her with the portfolio on Canada’s Arctic. I wish her well in her new position as Chair of the Arctic Council. I am ready to see what she will accomplish for Canada.

Preventing violence against Girls: developed for the UN Commission on the Status of Women

I am preparing for the United Nation’s Commission on the Status of Women which I will attend from March 3-8 in New York City. This year’s priority theme is elimination and prevention of all forms of violence against women and girls.

Canada’s Dr. Shelley Ross, BCMA President and MWIA Secretary-General, is a member of the Canadian delegation and so MWIA will make a presentation at the United Nations about the role medical women can play in eliminating and preventing violence against women and girls. My contribution to this will be to consider how violence against girls can be addressed.

The first question this raises for me is: Who is a girl? The definition is straightforward theoretically – from the Oxford dictionary: a female child or youth. In practice, however, the answer to the question becomes more complex.

One important aspect of violence against girls is that they are forced to be women or sexualized at too young an age. While we can say that this is less likely in our culture(After all, we don’t have a problem with child brides, do we?), exposure to adult themes and sexuality from a young age in western culture inculcates even the youngest girls into the mindset that they are only valued for their beauty. Thinness is part of that cult and, over the years, we have seen younger and younger girls restricting their diets in pursuit of beauty. (Hunger Pains: The Modern Woman’s Tragic Quest for Thinness by Mary Pipher) Our mixed messages around sexualization, beauty and thinness cause girls everywhere to grow up too quickly.

It does seem to me that we have forgotten that our task is to prepare a girl for the world so that she can approach it on her own terms and that a great part of that task is exposure to the realities of the world in such a way that she can incorporate her own response, which will change as her mind grows and develops. The growth and development of a mind include education and we are all aware that many girls around the world are denied an education. We must remind these countries of our responsibility to educate girls. In our own country, we are more successful with this, since many girls are now doing better than their brothers in school. They are still not doing nearly as well as their brothers in their careers or in gaining power since men still achieve tops job ranks and elected office much more readily.

Education for power and in careers is not learning acquired in a book and our culture continues to struggle with the concept of a woman as powerful, notwithstanding 5 women premiers. While so many women premiers is a good benchmark, the numbers of women on boards and in CEO positions continues to lag behind what one might expect.  We must find a way to supplement education with an education about power and gender so that girls can more easily take their roles running our corporations and governments and boys can more easily accept their roles as fathers and members of families. (If you think men are taking on more roles in households, have a look at any research about how much housework men do, compared to women.)

Jean Baker Miller described in her work on girls’ development the fact that young women often lose their self-confidence at a point when their need for relationships surpasses their need for autonomy. Miller describes a point at which a girl will shift her thinking in order to be more aligned with those with whom she has relationships. This point, to me, marks the ends of girlhood and, like all passages, it comes at different ages for different girls. When it comes too early, we see the consequences that can promote situations in which others are more important than the girl and she loses herself in her quest to maintain her relationships.  She also often abandons that most valuable of relationships, the relationship with her mother. This may happen more easily in poorer or single parent, female-led households where her mother is busy with all the tasks of parenting.

I only have 10 minutes in the Commission of the Status of Women Panel about what medical women can do to prevent violence against women and I know what my message will be, after I’ve talked about the basic public health information of violence against girls: Promote a girl’s relationship with her mother whenever you can. You’re always a girl to your mother and the longer you can be a girl, the better.