Drawing on his thought-provoking book From Paralysis to Fatigue, the University of Toronto’s Hannah Professor Edward Shorter took the subject of psychogenic disorders to family doctors last May.
Delivering the Hannah Lecture in the History of Medicine at the Annual Scientific Assembly of the College of Family Physicians of Canada, Professor Shorter found an audience with special needs.
“They haven’t been exposed to the work of historians,” says Professor Shorter. “It was a real personal challenge to say something meaningful to an audience of clinicians.
“It was quite illuminating for them to see how patterns of psychogenic illness change historically – to see something like paralysis be replaced by chronic fatigue syndrome.”
I worked as Editor and Writer for the newsletter of the Hannah Institute for the History of Medicine (under the direction of the Editor-in-Chief and Hannah Executive Director Dr. J.T. H. Connor) in the early 1990s. Located close to the University of Toronto and within a neighbourhood claiming a long association with medical and scientific discovery (Sir Frederick Banting, co-developer of insulin for the treatment of diabetes, lived at 46 Bedford Road,), the goal was to better connect Canada’s medical history community of scholars and raise the profile of the funding resources available to further the study of medical history in Canada.
If the results of a nation-wide survey of doctors are right, Canadian physicians love medicare but abhor government attempts to make them accountable for its costs. It also suggests that doctors are more willing to talk about cutting services to seniors and people with “unhealthy lifestyles” than to discuss cutting their own wages to save money.
However, according to some doctors, physicians’s anger with the provincial government is founded on ignorance and poor analysis of the larger forces affecting health care.
The survey, Breaking the Wall of Silence: Doctors’ Voices Heard at Last, was commissioned by The Medical Post, a national newspaper for doctors. It sent questionnaires to 12,000 doctors, receiving 3,087 responses. The Post also conducted in-person interviews to better gauge the mood of doctors.
The survey’s title is somewhat misleading, considering that doctors have been making noise over a number of issues this year; targets included proposed right-to-treatment legislation, cuts to the Drug Benefit Plan, capping of yearly billings at $450,000, and inquiries into charges of sexual abuse by doctors. And most significantly, the last conference of the Canadian Medical Association passed a resolution calling for a two-tier health system in which those with money can hop the queue.
Post editor Diana Swift says the poll shows fairly strong support for limiting services to the elderly, although the survey question is short on details: “I feel it is reasonable that access to high-cost services such as transplants should be rationed according to such parameters as the patient’s age and/or unhealthy habits.”
Yet just under 70 per cent of doctors opposed any capping of their salaries, despite 56 per cent of the public supporting this measure according to a 1991 Globe and Mail-CBC poll.
When questioned, Health Minister Francis Lankin expressed surprise that doctors felt so strongly, and denied the government is considering rationing services to seniors. Lankin feels the volatile mood of doctors is a reaction to the rapid changes taking place in health care.
Dr. Michael Rachlis, health care critic and author of the book Second Opinion, says the survey’s low response rate means that the answers reflect “redneck physicians, who are more likely to respond.” Swift admits to a high response rate from young male physicians, who since the 1986 doctors’s strike in Ontario, have been considered the profession’s most militant.
One response which some may find alarming was towards the “Oregon model.” In that American state, medical procedures are rationed to seniors and individuals covered by medicare. Anybody needing uncovered emegency treatment has to pay for it themselves. A disturbing 65 per cent of survey respondents supported such a move.
Dr. Gerry Gold, associate registrar at the College of Physicians and Surgeons of Ontario, feels that some doctors lack perspective. “The complaints are a reflection of frustration with increasing involvement of government. But if physicians understood the role of the government in the U.S., they would realize they, along with insurance companies, intervene far more.”
Gold says doctors have had the same complaints ever since the beginnings of medicare. “Many front-line doctors lack the information to make informed comment,” he says. “They aren’t being consulted or informed by the government.”
Rachlis says many doctors fail to realize how privileged they are. “Canadian physicians don’t realize medicare has protected their autonomy more than in the U.S.,” he says. “Doctors are always angry because they have large chips on their shoulders from being brutalized in their training. They don’t realize the government has given them a privileged monopoly over health services. With a guaranteed income with job security, I don’t know one doctor who has suffered in this recession.”
Gold doesn’t foresee strikes or job actions by doctors, but predicts further government cuts, and more services being de-insured by OHIP. A recent example involved removing coverage for third-party medical exams such as those requested by employers or insurance companies. As medical procedures end up outside of OHIP, Gold foresees physicians charging whatever they like.
A perennial idea is the user fee. This is one of the few ideas that gathers support from a majority of doctors and the general population alike. But Rachlis feels these measures are meanspirited and avoid the real problems plaguing health care. “When Saskatchewan introduced user fees for physician and hospital care in 1968,” he says, “health costs remained the same and it discouraged the elderly, the poor and people with large families from seeking service.
“When providers are allowed to charge users for care, as in the United States, where more than 20 per cent of health care costs are paid our of pocket, overall costs go up.”
A newly-formed group representing cancer doctors says it is fed up with the inhumane and bureaucratic approach to cancer care in Ontario.
Dr. Shailendra Verma of Access to Equal Cancer Care in Ontario (AECCO) says he’s had enough.
“My group has served the government notice that we’re fighting on our patients’ behalf,” says Verma, who faces gut-wrenching quandaries every day in his growing Ottawa practice. “In a public health system, I’m damned if I’m going to be divided into giving one set of patients a Cadillac treatment and the other Hyundai-type treatment; I don’t think that’s why we have a public health system.”
Verma says cutbacks to health care funding have meant that doctors must leap increasingly high hurdles to get the drugs their patients need.
In jeopardy
While chemotherapy drugs administered in hospitals are still free, he says the important drugs necessary for patient comfort and treatment effectiveness are in jeopardy.
These drugs were once free under the Ontario Drug Benefit Plan (ODBP), but now their status is tenuous. One drug, GCSF – which is crucial in helping patients between treatments of chemotherapy – is now listed under Section 8 of the ODBP and requires doctors to plead with the government each time for coverage. Often the bureaucracy moves so slowly that the course of chemotherapy is seriously disrupted, Verma says.
“As an oncologist I’m particularly interested in ensuring everyone has access to all treatment. I think we are at a very sensitive crossroads. Over the last three or four decades we’ve developed certain treatments for diseases that more often kill than cure. And now we are at a point where we’ve got new treatments that can make the older treatments more effective. Or we’ve got brand new treatments that we are hoping to apply, and the one thing that is holding us back is cost.”
Cost
“The decisions are not based on science, they’re based on cost. It would not be an issue if treatments cost a penny a shot.”
Verma says colleagues can’t introduce some new drugs because the costs would be too high to offer it to everyone. So no one gets it.
“We have patients who walk in and say they would like to pay for it,” continues Verma. “Ethically, as a physician do you allow a patient to pay for it while sitting next to a similar patient who can’t afford it?”
“Anybody going into medicine should read a whole bunch of good novels.” Dr. Alvin Newman isn’t kidding. The head of curriculum renewal at the largest English-speaking medical school in the world, the University of Toronto, feels strongly that doctors have been ill-prepared for their profession’s challenges.
How doctors become doctors is being hotly debated as Ontario’s five medical schools institute a potpourri of curriculum reforms. After a century of taking a back seat to scientific achievement, bedside manners and the art of medicine are in vogue again.
“Around the world, medical education is undergoing significant changes,” says Newman. “Medical schools must strike a balance between the incredible explosion of scientific knowledge and re-establish the role of the physician as wise counsel and empathic healer.”
It’s a role that many feel doctors have ignored. An American Medical Association poll, conducted between 1985 and 1988, found that fewer than 50 per cent of respondents said they thought doctors listened well and half believed doctors no longer care as much about patients as they used to.
In response to these criticisms, current reforms are shifting medical education away from reliance on the turn-of-the-century science-based approach, says Professor Jackie Duffin, a medical historian at Queen’s University who helped organize the new curriculum introduced there in 1991.
“In the old days doctors could probably make a diagnosis and tell people what was happening to them, but not do very much for them,” says Newman.
“Yet society had more trust and fondness for physicians than they do now. Much of the condemnation of the medical profession is because we have become the custodians of high-tech medicine.”
While the Ontario government embarks on the most sweeping reforms to health care since the 1966 introduction of comprehensive health insurance in Ontario and the founding of national medicare in 1968, many doctors feel their profession cannot afford to maintain the status quo.
The concensus at Ontario’s five medical schools – U of T, Queen’s, University of Western Ontario, University of Ottawa and McMaster University – has gelled around a belief that doctors need to be as comfortable dealing with people as they are with scientific medicine. To this end, revamped curricula supplement basic science and clinical medicine with emphasis on early exposure to patients, communication skills, psychological issues, medical ethics, medical literacy and health promotion.
These schools hope to produce new doctors to fit into a rapidly-changing health care system – one that many believe will rely far less on large hospitals.
Instead, many procedures will take place in the home or in the day clinics. Expanding community health care care centres will try to tackle extensive social and health problems. This preventive approach ot medical education was pioneered by Hamilton’s McMaster medical school.
Since its founding in 1967, McMaster has experimented with teaching methods that steer away from mass lectures to concentrate on the individual student. The evolution of McMaster’s curriculum has placed greater emphasis on communication skills, psychosocial aspects of medicine, community issues, and disease prevention and health promotion.
How do McMaster students rate against other medical students?
Last year they scored above the national average on licencing exams. A higher proportion of McMaster students enter research and academic medicine than their counterparts from other schools. One study comparing them to U of T suggested they were more motivated to be life-long learners.
Dr. Rosanna Pellizzari practices the kind of medicine everyone is talking about these days. Working out of renovated church, Pellizzari’s practice at the Davenport/Perth Community Health Centre in west end Toronto serves a working class neighbourhood that has been home to generations of recent immigrants.
A member of the Medical Reform Group – which has long advocated significant reforms to health care – and trained at McMaster, Pellizzari can be seen to represent the doctor of the future: Sensitive, salaried and working in community health.
“McMaster’s curriculum attracts people with innovative ideas,” says Pellizzari, who was active in community health education before going to medical school. “It is a very supportive environment.
“I think the important question is: Who do we choose to be medical students? They should open up medical schools to those who know what it’s like to be a parent, a mother or disabled. Doctors should represent the population they serve. We are still getting mostly white, inexperienced young males as physicians. They aren’t going to practice the way that is necessary.”
In Ontario, many doctors see the 1986 doctors’ strike as a watershed for public opinion.
As a result of the negative fallout from the strike and perceived gap between physicians andhe public they serve, a five-year project entitled Educating Future Physicians for Ontario became a major advocate for reform.
Started in 1988, EFPO has examined fundamental issues in designing and implementing new medical school curricula. These issues include defining societal health care needs and expectations, faculty development and student evaluation. While each medical school has adapted reforms to its particular situation, EFPO hopes to prod further reforms.
“This is a unique venture in Canada, and could have implications far beyond Ontario if successful,” says Dr. William Seidelman, a key player in EFPO. “It captures the unique sense of the Canadian scene, and will build on the implied contact in the Canadian health system.”
Pellizzari sees the attitude of medical schools and teaching hospitals towards medical students as a significant factor in creating insensitive doctors. She recalls the high rate of suicide among medical students and the abusive work environment that forces doctors-in-training to work shifts unthinkable for other workers.
“The way we train doctors is inhumane,” she says. “We don’t expect other workers to put in 30-hour shifts. It creates in new physicians the attitude that they paid their dues and now society owes them.”
Many critics feel that changing training methods isn’t enough; the whole ethos and selection process must be changed. If doctors are to better serve the population, they must better reflect it.
“We are getting very close to gender equality and a laudable distribution of ethnic and racial backgrounds,” says Newman. “But students still come from a fairly narrow social spectrum, very middle class kids. Their exposure to the extremes of society, to poverty, to homelessness and related illnesses have been very limited.”
Pellizzari found how out-of-date the medical profession was in her first year. One teacher wanted her to work till 10 at night. When told that she needed 24 hours notice for a babysitter, the teacher shot back that motherhood and medicine don’t mix.
“I was a mother before I was a physician. When I get a call at night from a mother, I understand this. With 30 per cent of visits to doctors having no biological basis – like depression due to unemployment – you can’t do anything unless you have experienced life.
“If we don’t address this, you can design the best training in the world, but things won’t change.”
But Newman also feels many factors outside of medical school discourage a more diverse student body.
“To go through medical school in the United States requires large indebtedness. That’s not true in Canada. You can calculate what a year of medical school costs in terms of a finite number of CDs, a leather jacket and ghetto blaster. So something is dissuading people from pursuing this career, and it isn’t money.”
While there is a concensus among academics that medical schools haven’t prepared doctors well enough, there is little support for a dramatic change in selection criteria. “I can’t muster a lot of support from colleagues for serious changes,” says Newman.
Dr. Jock Murray, the former dean of Dalhousie medical school in Halifax, recently told an EFPO meeting he doesn’t see any significant changes ahead.
“Physicians have a reputation for being conservative and self-serving,” says Murray. “If reform is going to be successful we have to be clear that it is about what is good for the people.”
Pellizzari believes life experience and empathy with social circumstances just can’t be taught.
“I grew up in this neighbourhood. I understand their powerlessness, the conditions. Doctors have to see themselves as a member of a team of health professionals, not as the top of the social and medical totem pole.”
U of T’s experience is a classic example of the hurdles ahead. Newman admits it has come as a shock to students loaded with society’s ingrained expectations.
“They spend half a day a week in the community seeing things like drug rehab clinics and community health centres. But being out in the community doesn’t make the students feel comfortable. Their image of what they are going to do involves big buildings, chrome and steel, scurrying personnel and banks of computers.”
“… in recent years it has become a pursuit for a growing number of researchers. … Behind much of this growth has been the Hannah Institute for the History of Medicine …”
David South Consulting 
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