MARCH 25, 1976
Health Care in a New Society
AN ADDRESS BY Dr. lain A. D. Todd,
VICE-PRESIDENT, ONTARIO MEDICAL ASSOCIATION
CHAIRMAN The President,
H. Allan Leal, Q.C.
Ladies and gentlemen: We bid you a cordial welcome on this fine spring day to the luncheon meeting of The Empire Club of Canada. This is health sciences day at the club and I am eager to have you meet our distinguished head table guests.
I suspect that if our distinguished guest and speaker had had any choice in the matter, he would not have chosen on this occasion to put his life and reputation in the hands of a lawyer. Also, I think it only fair to Dr. Todd to add that I intend to postpone any reversal of these roles for as long as possible. In the mid-seventeenth century, Thomas Fuller wrote that "commonly, physicians, like beer, are best when they are old; and lawyers, like bread, when they are young and new." If that be right, it is an unhappy circumstance in the fates of chronology that you have been saddled with a young doctor and an old lawyer!
I would not wish in any way to anticipate what Dr. Todd may wish to say to you, and he certainly has not asked for my advice, so I shall not offer it. But I would, with respect, offer the advice of one of the greatest lawyers, Roscoe Pound, who in addressing himself to the question "What is a profession'?" gave his own answer in these terms: "Historically, there are three ideas involved in a profession, organization, learning, and a spirit of public service. These are essential. The remaining idea, that of gaining a livelihood, is incidental." And that, in my opinion, is a much better and sounder view of the matter than the characteristic cynicism of George Bernard Shaw who said, but perhaps did not believe, that "all professions are conspiracies against the laity."
As one might have guessed from his name, Dr. fain A. D. Todd is a Scot. He took his medical training at Cambridge and St. Thomas' Hospital Medical School in London and his surgical training at the University of Toronto. He was a travelling scholar for a year, studying surgical transplants and paediatric urology in England and on the continent and returned to the staff of Toronto Western Hospital where he performed the first renal transplant in the new series in Toronto. The present generation of renal transplant surgeons owes much to the pioneer work of the late Dr. Gordon Murray.
After joining the staff of Scarborough General Hospital in 1965 for two years, he then became chief of the urological service at the new Centenary Hospital in Scarborough.
Dr. Todd is a past chairman of the Ontairo Medical Association Section on Urology, a past chairman of the Urology Section of the Academy of Medicine, and a Past President of the Scarborough Clinical Society.
He was elected to the Board of Directors of the O.M.A. in 1971 and served two years on the Executive as Honorary Treasurer before his election to the office of Vice-President in 1975.
It is a privilege for me to invite Dr. lain A. D. Todd to address us on the subject "Health Care in a New Society".
I thank you for this opportunity to share with you some thoughts about the new society that is being created for us and its effects on the physician as a professional, as a provider of health services, as a major taxpayer and as a citizen.
If it seems presumptuous for a physician to address such an august body as the Empire Club on a predominantly social issue, let me assure you that I do so with some trepidation, and appropriate humility. But physicians traditionally have confined their public utterances to professional matters, and there is a growing feeling among doctors, which I share, that it is time for us to declare ourselves on social, economic and political issues. We dare to do so not because we have any special expertise in this area but because our professional lives, as well as our personal lives, have been changed dramatically by the new social order during the past decade. Indeed, the erosion of our traditional freedom, in terms of both professional practice and earning capacity, are such that we have the paranoiac feeling that our profession has been singled out from among all of Canadian society for extraordinary control.
Some of us in this room are old enough to remember the days when a person needing medical care sought out the services of a physician, and in so doing entered into an implied contract: the physician agreed to advise and treat the patient to the best of his ability, and the patient agreed to pay the doctor's account for those services. All this changed when government decided to take over our health service through the aegis of national health insurance. Now the physician agrees to advise and treat the patient within the limits allowed by OHIP, and the government, not the patient, agrees to pay the doctor a fee negotiated over the bargaining table. The patient's only obligation is to see that his OHIP premium is paid, by his employer; by the government or, in rare instances, directly by himself.
If our paranoia about control seems unwarranted, let me tell you about some of the controls that have been imposed on our "free and unfettered" profession:
- We are now governed by the Health Disciplines Act, which requires the presence of non-medical persons on the Council and committees of the College of Physicians and Surgeons, the licensing and disciplinary body. It also provides for a Health Disciplines Appeal Board, made up entirely of people outside the health professions, to hear appeals from decisions of the Complaints Committee of the College.
- The Ontario Council of Health, senior advisory body to the Minister, is dominated by non-medical persons.
- The Hospital Appeal Board, which hears appeals from physicians unable to obtain hospital privileges, is made up mostly of persons distinguished by their service to hospital boards, which. in these cases are the adversaries.
- The medical profession has only token representation on District Health Councils, which are to be the authoritative local bodies overseeing the delivery of health care in this province.
- And there is a "public presence", in the form of the chairman, at the bargaining table where the Ontario Medical Association negotiates OHIP payments with the government.
We hope that consumerism in the health care field eventually will prove to be more successful than it has been in other areas of endeavour.
We wonder about people on the one hand demanding industrial development to share the tax load and provide high employment and on the other hand demanding that government close down industries because they contribute to environmental pollution. And we wonder about governments that succumb to demands of environmentalists and require automobile manufacturers to reduce pollution emission of cars to the point where fuel consumption is a bad joke, only to be forced to make an about-face and require those same manufacturers to increase gas mileage to conserve fuel and prevent, or at least postpone, the extinction of the automobile in North America.
We also wonder about governments that become so carried away with their own rhetoric on the subject of health costs that they will resort to such extreme measures as closing hospitals. The closing of a hospital is a devastating blow to the community it serves. In most cases, hospitals were built by the community and at least part of the cost was provided through fund-raising campaigns and municipal debenture issues. If a hospital is closed the community may be left with an empty building which can be converted to other uses, but what of the millions of dollars' worth of equipment? More importantly, where will the citizens receive hospital care in the future, and how will those without cars get there? In small communities the hospital often is a major industry employing a significant proportion of the work force, and the closing of the hospital could be an economic disaster for the town. Doctors on the medical staff of hospitals to be closed must seek appointments at adjacent hospitals or leave the community. A small urban centre which loses its hospital will also likely lose its resident physicians because efficiency dictates that the doctor's office should be near his hospital.
I do not propose to debate whether this or that hospital ought to be closed. But I am quite prepared to debate whether the closing of hospitals is a proper course of action as a means of reducing costs.
Politicians and social planners throughout North America have been screaming for years about the "crisis in health costs", yet there is no evidence that a crisis exists, in Ontario at least, any more than a crisis exists in every segment of public expenditure. As proof I offer statements made a few weeks ago by the Minister of National Health and Welfare. He stated that Ontario's health-related expenditures have actually declined, as a proportion of the provincial budget, during the past decade. In the pre-medicare days of 1967-68, healthrelated expenditures represented 31% of Ontario's provincial budget, and in the current fiscal year, 1975-76, they represent only 30%. And as for physicians' services, the federal minister tells us that Ontario citizens in 1973, the last year for which figures are available, spent on physician's services precisely the same proportion of their personal income, 1%z%, as they did in 1969, which was virtually pre-medicare.
I should point out that the federal minister gave out these statistics to refute an argument by the Ontario government that its contribution to medicare was rising. But when he was proposing legislation to control federal medicare contributions, the minister painted a quite different picture of rising costs.
So we have the federal government trying to back out of its commitment to medicare and the provincial government cutting services to reduce its commitment. Nobody bothers to ask the citizens whether they would prefer increased premiums, increased taxes or a reallocation of tax money rather than a reduction of services.
Despite all the bleating about rising costs, our governments insist on maintaining their monopoly in the field of medical care insurance. The medical profession has been telling them since before the introduction of medicare that compulsory, state-run medicare is less efficient than the system that it replaced, in which the government looked after those in financial need and left the rest of us to buy our own protection, or to take our chances and pay our health costs as they arise. We still believe, with Abraham Lincoln, that "in all that the people can individually do for themselves, the government ought not to interfere". And events of recent years merely confirm our conviction that medical insurance, family allowances and all other welfare programs should be restricted to those in need. In these circumstances the taxpaying citizens can decide for themselves the quantity and quality of services they want, and how much they are prepared to pay for them.
Even now the government could allow private money into the system by restricting the benefits of medicare to a basic plan, as is the case with hospital insurance. There might be an extra charge for those demanding extra service, or a patient participation fee charged to everyone able to afford it. This kind of flexibility would make OHIP a better plan. Yet the government wants all doctors on the OHIP payroll rather than dealing with their patients, in spite of evidence produced during its early years that OHIP's average cost per patient was less when the doctor billed the patient than when the doctor billed OHIP.
There is a terrible touch of irony in all this. The governments which are perpetrating this cruel hoax of runaway health costs on the population at the same time are profiteering from the sale of alcohol and cigarettes, which contribute substantially to cause and the cost of illness in our country. The Ontario government alone takes in more than $500 million a year, half a billion dollars, from the sale of alcohol and tobacco. And the Ministry of Health goes to the extreme of closing hospitals to save $50 million, less than 2% of the health budget. To give another perspective, Canadians spend about five billion dollars a year on alcohol and tobacco, and that's as much as the federal government and all provincial governments spent on medicare cost-sharing from 1968 to 1974.
Governments are not alone in the field of public deception. Just recently a politician outside the government made headlines by misinterpreting a computer printout of our Laboratory Proficiency Testing Program, which the province's more than 500 laboratories participate in as a licensing requirement. The news media obediently published the politician's press releases, probably because he claimed that the computer printout, which is sent to all the labs, was a secret document, and because he talked to a few people and called it research.
The truth is that this proficiency testing program is the result of several years of development by my colleagues in the field of laboratory medicine, working through the Ontario Medical Association. Although it is still in its infancy, it is considered internationally as a model in peer review, and it will ensure that the quality of laboratory work is maintained at acceptable professional standards. Publicizing errors in test results might give the public some unwarranted fears about the competence of medical laboratories, but it will in no way improve that competence, which is the goal of our program. As a matter of fact, the politician's proposal to have all laboratory work done in government and hospital labs would solve nothing, for there is no clear pattern of proficiency separating these from the private labs.
There has been publicity recently about members of the medical profession allegedly receiving "kickbacks" from medical laboratories to which they referred their patients for lab tests. Several cases will be heard by the Discipline Committee of the College of Physicians and Surgeons of Ontario within the next few weeks, and I will make no comment on them. However, I want to assure you that the medical profession, through its Code of Ethics and regulations of the College, very clearly and firmly sets out a standard of conduct which prohibits the acceptance of "any commission or payment, direct or indirect", for any service rendered to patients by persons other than the doctor's own employees and professional partners.
One of the legal methods physicians use to improve their economic status is to acquire real estate, and while this is obviously a good investment it sometimes can create problems. For instance, one of my colleagues in the specialty of urology had acquired over the years a couple of apartment buildings, which he foolishly attempts to manage. One night he was awakened by a phone call from an elderly gentleman who said excitedly: "My water's been cut off!" The sleepy urologist replied: "Are you a patient or a tenant?"
Another popular topic in the news media is unnecessary surgery. The subject was debated at great length when a former Minister of Health, who thankfully is now back practising law, stumped the province telling anyone who would listen that doctors were cutting up their patients indiscriminately to increase their incomes. This month a reporter dredged up a four-year-old peer review report on gynaecology in Saskatchewan, threw in some questionable research comparing raw statistics from Ontario and Britain, and made a four-part series of articles out of it. We believe this to be monstrously irresponsible journalism.
It's absolutely ludicrous to compare medical care in the U.K. with Canada's. My father practised under the National Health Service but I will resist the temptation to describe the horror stories that I have heard. Just let me make some obvious points:
1. Britain is going down the drain economically. The value of the pound sterling in relation to the Canadian dollar has dropped by one-third in the past decade, from more than $3 in 1966 to less than $2 in 1976. If there is less surgery done in Britain than in Canada, it's no wonder. Let's face it, there's less of everything in Britain today.
2. Canada has benefitted, and Britain has lost, through the mass exodus of physicians from the U.K. As the London Daily Telegraph commented on October 8, 1975: "The doctors are packing up and going. Some of the best have gone, leaving unfillable gaps. Many of those who remain are old, presumably too old to go. Of young men now training to be doctors, many have no intention of practising in this country." The Daily Telegraph editorial concludes: "Perhaps the doctors by their exodus will bring home to our government and people the appalling and often irreparable injuries now being inflicted on our country."
3. Controls and restrictions on hospital utilization in the U.K. are such that it is very difficult for any surgery, necessary or unnecessary, to be done. The British people have just had to learn to live with conditions that could be corrected surgically because of the interminable waiting lists at hospital--a year, would you believe, for a hernia repair, and two to four years for cataract surgery. Patients there have become cynical about the hospital waiting lists and wonder whether the health planners consider "d.o.a." dead on arrival--as a tragedy or a cheap diagnosis.
4. The National Health Service is so totally socialized that they don't even keep accurate records of the numbers of surgical operations performed in the country. Their statistics are based on an assessment of 10% of hospital discharges, hence comparison with Canadian statistics are odious.
Let me assure you that there is unnecessary surgery being done in Ontario. There always has been, and always will be, so long as medicine remains an inexact science, depending as it does upon human judgment. But what is unnecessary? If a breast lump is removed to exclude cancer and the lump is benign--is that unnecessary? I think society believes that it is better that some unnecessary surgery be done than that some necessary surgery not be done. We don't really have a choice, because although we have excellent diagnostic aids, it is often impossible to determine until the tissue is removed whether or not it is healthy tissue. And in some cases, tonsils are a good example, surgery sometimes can be justified whether or not the tissue is "healthy".
To say a doctor removes a child's tonsils purely for economic reasons is absurd: treating tonsillitis and associated diseases throughout childhood would yield many times the fees of a single surgical procedure.
Tonsillectomies, with or without adenoidectomies, have been a subject of debate within the profession for many years. New drugs and changing concepts alter patterns of practice in medicine, and tonsillectomies again are a prime example. In 1967 there were 87,000 tonsillectomies done in Ontario. During the current twelvemonth period, based on OHIP statistics for the first six months, there will be about 42,000, less than one-half the number done by fewer surgeons among a smaller population nine years ago. Medical staffs of nearly all hospitals in Ontario have tissue and audit committees which carefully screen laboratory reports of tissue removed during surgery, and surgeons whose judgment does not meet acceptable standards are dealt with by the governing board of the hospital on recommendation of the Medical Advisory Committee. The most common disciplinary procedure is restriction of surgical privileges.
This kind of self-discipline is one of the hallmarks of a profession, yet the activists, including the news media, tell us it isn't good enough in the new society.
Perhaps these few examples I have cited will be sufficient to support our thesis that the medical profession has been subjected to a series of controls and assaults on its freedom and is in danger of losing its professional status. Those of you who are in other professions, in business and industry, in every walk of life, should gird your loins because political history shows that almost nothing short of revolution will change the direction of the current of political trends.
A major thrust in the campaign to entrench the new society was the Anti-Inflation Act. Another salvo comes in the form of amendments to anti-combines legislation which, among other things, prohibit professionals from adhering to their own fee schedules, unless they conspire with government to set them. I have no doubt whatever that these measures are deliberate steps toward the total centralized control of Canadian society.
There are other giant steps that have been taken in the same direction. For example, the erosion of the supremacy of Parliament; the growing trend towards rule by Order-in-Council, and the frightening interference by the legislative branch of government into the judicial branch, whose total independence is a cornerstone of our democratic system.
There is another, unrelated example of the inflexibility of government policy which has come to my attention, and which I mention because some of you people might have influence in high places. It concerns the 1976 Olympiad for the Physically Disabled, which is to be held in Toronto in August. The federal government refuses to support the project if a team from South Africa is invited to participate. The basis of this attitude is the government's opposition to the apartheid policies of the South African government. Yet the South African team of 22 disabled athletes is an integrated, multi-racial team which includes nine non-whites. The team was selected at trials run by the South African Sports Association for Paraplegics and Other Physically Disabled, which, since it amended its constitution to prohibit racial or political discrimination, has been accepted into the membership of the International Sports Organization for the Disabled. Surely a nation that welcomes terrorists to international conferences within its borders and issues visas to able-bodied South Africans to visit Canada should open its gates and its heart to physically handicapped athletes whose acceptance of the brotherhood of man shines like a beacon in darkest Africa.
As I said at the outset, we as physicians are concerned over the direction in which society is being taken. We don't know how far our leaders can or will go or whether there is any chance, even now, of reversing the trend. We find both hope and despair in the words written 450 years ago by Niccolo Machiavelli: "There is nothing more difficult to take in hand, or perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things."
Our distinguished speaker and guest was thanked on behalf of the audience by Lieut. Col. E.H. Shuter, C.D., F.C.I.S., a Director of The Empire Club of Canada.