Dr. Brian Day @DrBrianDay Twitter

  • Past President Canadian Medical Association
  • Past President Arthroscopy Association of North America
  • Honourary Associate Professor University of British Columbia
  • 2014 Doctors of BC Don Rix Leadership Award

Building a Culture of Putting Patients First®

Sep 29, 2007

Canadian Medical Association

Dr. Brian Day
Canadian Medical Association

Thank you for the introduction, and I am very pleased to be here today and to represent the CMA as its President.

Your President, Gerry Kiefer, is of course also an orthopaedic surgeon. We are often looked upon as the not too smart medical mechanics or carpenters of our profession. When bones or joints are broken or not functioning well, we try and fix them. I don't believe the Canadian health system is functioning well. It needs fixing. Like many of you, if I didn't think that was possible, I would not be here today.

The theme of my remarks, "Putting Patients First" is familiar to you all and was used for my inaugural CMA address. I thank Merck, sorry I mean the AMA, for allowing us to use your signature phrase.

I would like to first discuss 2 Alberta-inspired issues, one negative, the other a positive. Professionalism Under Fire

The negative refers to Bill 41 which was discussed at the CMA Board this week. Your representatives, Drs. Lee, Ballantine and your president Dr. Kiefer, made your colleagues from across the country aware of this issue.

As Dr. Kiefer stated "this bill represents an unprecedented and unnecessary intrusion into the self-regulation of the medical and other health care professions."

While we support a major role for government in health care, we must also recognize the potential for harm when political issues override the needs of patients. Despite the best intentions of politicians, I believe patients prefer to trust doctors with their medical issues.

Patients have been well served by the College of Physicians and Surgeons of Alberta for over 100 years. Doctors know that self regulation is a privilege, not a right. We have earned that privilege and Bill 41 is an attack on our integrity and our code of ethics.

Governments should question the wisdom of the further politicization of health care that has resulted in a rich and successful country like Canada having one of the most expensive yet lowly ranked health systems in the developed world.

The CMA stands by its Alberta members on this Bill and will continue to support you at the national level. Information Technology

The second Alberta-nspired theme relates to information technology. This is a priority the CMA shares.

I bought my first computer, a Radio Shack Tandy in 1978. In 1979, I sponsored a paper on electronic medical records by then-orthopaedic resident Dr. Myles Clough. A UBC summer student of mine became so interested that he switched from commerce into computer science, later becoming an assistant VP at Microsoft in Bellevue. He retired as a very wealthy man in his early 40's.

In large part through the efforts of the Alberta Medical Association, your province is leading the country in IT, and I want to commend your President for the speech he made last week in Edmonton. It is probably the best overview on this topic ever presented in Canada.

Record keeping, communication, data and information sharing will lead to better and safer patient care and governments will benefit from tremendous cost savings. Physicians are subject to a free market in expenses, but not in revenues. Governments must understand that the adoption of EMR by doctors will require additional resources, but the return on investment for patient care and health care costs will be substantial.

I would like to briefly reiterate some of the issues - issues that I believe governments need to act on now - that I raised in my inaugural address at GC.

The Canada Health Act

Two years ago, the highest Court in the land - in the Chaoulli decision - ruled in favour of the right of patients to insure their health when the public system fails to deliver on its promises. Similar - indeed more persuasive cases - are coming soon to Ontario and Alberta.

Governments appear to be in denial of this reality, even as patients wait for care and physicians grow more frustrated at being unable to provide timely access. This is where governments should put their efforts - in making things better for patients, not, as in Bill 41, through expanding existing government bureaucracy.

Governments must address access and wait list issues. Alberta has made progress in hip and knee replacements, but other patients continue to suffer and wait.

Frustrations with wait lists led me, in 1995, to found the Cambie Surgery Centre in Vancouver - the first private facility of its type in Canada. The motivation behind our group was simple. Our services were being rationed. Personally, my OR time dwindled from 22 to 5 hours a week. That is 10 hours less than the minimum recommended for competence by the Canadian Orthopaedic Association.

We built our own place to work because the public hospital would not allow us that privilege.

We opened during the tenure of perhaps the most left-wing NDP government that Canada has ever seen. That is a story in itself. Our centre spawned others, and we have become a valuable part of the BC health system.

For our troubles, we have been accused by unions, some so-called consumer groups, and by even a fringe doctors' group of promoting a so called 2-tier, American style system. Our health system has been ranked 30th by the World Health Organization. The U.S. was ranked 37th. I don't know a single person who wants to copy the US system.

Demands for health care increasingly exceed supply. The World Health Organization has stated: "if services are to be provided for all, not all services can be provided." Let's face up to this fact.

Advocates of the status quo ignore that we already have a multi-tiered health care system that allows selected Canadians, such as WCB, RCMP and others, access to quicker and better care.

They ignore the fact that the terms "Medically necessary or required" are used widely in legislation, but have never been defined.

They ignore the fact that patients are charged for "upgraded" implants and devices by public hospitals, and a host of other items prescribed by physicians.

Until I get answers, I will continue to ask how can crutches used after breaking one's leg, or an ambulance for someone who has had a heart attack, not be "medically necessary"?

How can antibiotics prescribed to fight an infection, or painkillers to relieve pain, not be "medically necessary"?

Moving forward, there are key challenges.

Health Workforce

The first is the shortage of doctors. In 1970, when public insurance was first fully applied to physician services in Canada, we ranked in the top 4 among developed countries in the number of physicians per capita.

We now rank a lowly 26th. Each year, between 1993 and 2004, the equivalent of two full medical schools of graduates has left Canada.

Fifty per cent of all newly trained orthopaedic surgeons and neurosurgeons leave within five years of graduation. They leave because we can't offer them the resources they need to work. They graduate with average debts of $160,000, and are forced to factor in their debt as they make career choices.

Compounding this issue, young doctors rightly look at my generation and say "get a life". Similarly, the feminization of medical schools is a statistical reality and brings with it different practice patterns.

Preventative medicine is wonderful, but does not always save money and keeping us alive longer is desirable, but it's proving to be costly.

Defenders of the status quo often promote the evils of private care and private insurance. They do so secure in the fact that they and their families have private health insurance, accepting for themselves what they reject for others.

Health care is facing a demographic tsunami as our society ages and we see more and more chronic diseases. There will be an astounding 43% increase in the over 80 population in Canada by 2011, and their health care costs will create an economic crisis.

Consider just one operation in my specialty: Tell me who will perform the projected 670% increase in the number of knee replacements? Who will fund them as the general workforce shrinks to a level that will not provide enough tax revenue to pay for them?

Currently, we rank near the bottom of OECD countries in access to technology. It seems that as new technologies evolve, we will just not have access. How can that be when we are a rich country that spends so much on health care?

The over-65 population in Canada stands at its highest per cent level in history, while the under-15 population is at its lowest. I have tried to correct this imbalance through fathering 6 children, but it is clear that I need to do more.

From 2001 to 2006, government health spending has risen from $106 billion to $148 billion a year. Michael Murphy, NB health minister, stated a few weeks ago that health spending was rising at twice the rate of government revenues. Premiers and ministers of health are saying the only ministries they will soon be able to afford are the Ministries of Health. They are wrong of course... they will need ministries of revenue to collect the taxes to give to the Ministries of Health.

We must reject waiting periods that exceed all ethical and medical standards. They do not exist in many other countries with universal care, and they need not exist here. Wait time guarantees and benchmarks were no more than a good start. Their limitations and the potential for litigation are issues that are now being raised.

Waiting patients deteriorate as they suffer physical, emotional and financial hardship. Wait lists impose a huge financial burden - many billions of dollars - on the health care system.

Governments need to understand that it will be cheaper to have no wait lists. Their elimination will prove a worthwhile investment.

So where we go from here depends on how we answer some key questions:

First: Is it not time to update and modernize the Canada Health Act, whose principles were developed over 45 years ago? That was an era when there were no CT scanners, MRI's, by-pass surgeries, joint replacements and so on. Efficiency, Effectiveness and Responsibility - principles that Tommy Douglas described as essential parts of any health legislation, need to be added to ensure accountability.

Second: What is the role of private insurance within the public system? Since 70% of Canadians have it, let's not ignore the fact, but figure out how to use it better.

Third: Why is the implementation of good business and market principles restricted in our public system?

We need a system that treats health workers, including physicians, hospitals, and most importantly patients as value centres - not as cost centres. The elimination of block funding as the main payment mechanism for hospitals will breed efficiency.

Patient-focused funding, where the money follows the patient will bring increased market efficiencies into the system. We are the last OECD country that almost exclusively block funds its hospitals.

The introduction of patient focused funding will both empower patients, and allow government institutions to generate revenue from our health industry.

The world's biggest consumers in the 40-billion dollar medical tourism business are the Americans. This is a business that doubled in size this year, as half a million Americans travelled abroad for care. They did not travel just slightly north to a modern country, with superb health workers and facilities. They went to Thailand, India, Europe and Russia. Many Canadians travelled to those same countries - and to the US, spending billions of dollars to access care they couldn't get at home.

This is a potential massive new industry for Canada, and could grow to be our biggest. A pre-requisite is the elimination of our own wait lists - and that is an attainable goal. Remember, since Canada has virtually no non-government hospital infrastructure, the potential income from medical tourism will benefit public hospitals and unionized workers.

Let me make one point clear. Canada's doctors believe that access to quality health care services must be available to all Canadians based on need, not ability to pay.

However, I do support a role for the private sector. If certain services can be delivered better and faster and perhaps more cheaply in the private sector, then governments have a moral and fiduciary duty to use taxpayers' resources wisely.

I presume that was Roy Romanow's motive when, as Premier of Saskatchewan and a vocal advocate for public health care, he privatized laboratory services there 16 years ago.

The public/private debate in this country is, in my judgment, largely irrelevant. Much of the rhetoric is not about saving Medicare, but about defending unionized jobs.

We understand why union-funded groups, such as the various so called health coalitions, continue to advocate for their members. But let us be clear. They are fighting for the rights of their members, which is understandable since that is their job. They are not fighting for the rights of our patients.

In closing, we are focused on putting patients first. How can we achieve our goals?

We must fight the tedious public-private rhetoric.

We need more resources for rural health and chronic care, especially mental health. We can generate those resources through savings achieved by the introduction of market principles into the public acute care system.

The CMA and provincial medical associations must insist on urgent reform and action. We are a rich country, and Canadians should not wait for access.

Here, in the hometown of our Prime Minister, I would like to send a message from the CMA. Mr. Harper: the job is not done. In fact, it has barely started. We need action now. The clock is ticking, and time is not on our side.

Thank you.