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An exit interview with outgoing CMA president Dr Robert Ouellet

SASKATOON -- At this week's Canadian Medical Association annual meeting, in Saskatoon, the organization's presidency will pass from Montreal radiologist and entrepreneur Robert Ouellet (right) to Saskatoon family physician Anne Doig.

I spoke to Robert Ouellet about his experience as president and what he thinks is next for the Canadian healthcare system.

SAM SOLOMON: Do you see your presidency as a success? Were you successful in accomplishing what you set out to do? And obviously I realize you can't fix the whole healthcare system in one year.

ROBERT OUELLET: [Laughs] I said that in my inaugural speech that I would try. I still have one week!

It'll be a busy week, I guess.

I know. But I think we have succeeded in trying to change the attitude in Canada of only looking at the US system -- and it is a little bit back now because of what is happening in the States. But because we took a look at what is going on in some European countries, it changed the attitude a little bit. Meaning that we know we have seen it's possible to have a universal system that doesn’t cost more than our system – or even less – and where there's no significant wait times. And this should be our goal, to try to transform our healthcare system so this becomes possible here.

And you see your presidency as having laid the groundwork for somebody to move towards that in the future?

Yes. What we are doing right now and the culmination of my year is the framework we will present at GC [CMA General Council] this coming week, which is the base of the changes and what we want to do. And of course this will have to be implemented after. It's now time to move on it. We have done the studies. They were done previously. Enough of studies. We now need to do something.

Can you give me an idea of what that framework will look like? How close is it to the models you studied in Europe?

These [visits to Europe] were only to look at what they were doing. We cannot import everything, and there's no perfect system. One thing we believe we need to change is the way we are funding hospitals. Here we have global funding, block funding. We are probably the last one to have that, the last developed country. What we need to do is to change that, at least partially, to what we call activity-based funding. Then the patient becomes the revenue instead of an expense, and it changes the attitude. And to give some incentives to quality, I think this is very important.

This is an issue that I think was first presented at the CMA by Brian Day. Is this something there's been any progress on? Both you and Brian have been describing it for a couple of years now. Is anybody listening in Ottawa?

Maybe not in Ottawa, because in Ottawa they say, “Well, this is a provincial thing.”

I know there was some interest in BC.

Yes, there is interest in BC, there is interest in Ontario, there is interest in Saskatchewan. There is interest in some provinecs because they feel it is the way to do it. We met with a lot of provincial organizations and health ministers. Even the Ontario Hospital Association, they are ready to move with that kind of system.

Do you think this is something that could actually happen within the next year or two?

I think so, I think so. And I think the way to do it is probably to take one or two provinces as leaders and try to implement something, and the others will see the example and they will follow. I think it's the way to do things. Because, you know, we have 14 different healthcare systems and they're not at the same level of organization. And so if one or two provinces are ready to do that, well, I think that is probably what will happen. Anyway, we cannot control that.

Do you have any guesses as to whom those leader might be? Are you talking about BC?

Probably. Maybe. Well, I don't want to take a decision for them. They seem to be more open-minded about that. Even Ontario seems to be more open-minded -- at least the OHA. I don't want to talk for them. It's a possibility that some provinces will move on that. At least partially.

One of the other big issues that you and Brian have spoken about over the last couple of years is wait times. That was in the news a lot when Brian first became president but it seems like it has receded from the public consciousness a bit with the recession, like people are less interested in healthcare and wait times here at the moment.

Yes, but the problem is still there. And because of that economic problem it [wait times] will be a bigger problem because there will be probably less money to put in the system. So we really need to improve the system. This is the big drawback of our system, the wait times.

We've known that for a few years now. Ten or twenty years, even. But still nothing has changed, largely. We've had proposals, and a couple of years ago we had the wait times guarantees the Conservative government introduced and the provinces began using.

Yes, but there is no guarantee. In most places it's not a guarantee. We have to say there have been improvements, but it's not enough. People are still waiting way too long. And if we compare ourselves to those European contries, what we give an A grade here could be an F grade in those countries. People were very surprised when I told them our target for hip replacement was six months. They said, “This is your target?” and they couldn't believe that.

That's what a number of doctors here said when the wait times guarantees were introduced, as I recall. I wrote an article on radiation oncology at the time and some doctors were really upset that the targets were far, far longer than their actual targets were.

Yes, because it's not acceptable to have targets like that. And then you have to reach those targets first, and even the targets are not enough. This is the biggest problem of our healthcare system right now.

And so what is in the new framework plan you are planning to present at the CMA General Council meeting this week about reducing wait times?

Well, we have a plan – it's a little bit hard to describe, because it's a framework. We need to put patients at the centre of system, meaning it's the needs of the patient that should be at the centre of the system -- not the system itself. What we will be asking doctors at GC next week is “What do you think you can do as doctor to improve access?” Because it's very nice to say to everyone to do this and this and this, but what can we do as doctors to have more patient-focused care? let's say for primary care, for Gps, there are some techniques that exist, like one called Advanced Access. This could improve a lot the access to family physicians, without costing money, just [by changing] the way we are doing things.

Is that something the CMA is going to take up in its lobbying to the provinces?

Yes. What we would like to do is, we know there are a lot of pockets of excellence. There's a better word for that but, you know, I'm francophone... There are ways to do things that are very good here in Canada and elsewhere, and we must put that together and spread those best practices. Best practices – you know, the way to do things more appropriately. Sometimes something is done in a small area or one part of one province, and if it is working -- well, it could work everywhere. The CMA could be the place where we collect all those good practices and then try to explain and spread the good news.

Have you learned anything about policy in your time as CMA president that will affect the way you practise?

What I have been doing in my career previously is to try to give access to MRI and CT, and this is why we have built those clinics, because the access was so awful. You know the story: we offered to a hospital in the beginning to buy a machine becaeuse there was no machine in the public system. This is one way to improve the access, but it's not the best way. It's not the privatization of system. We could help with some private clinics. Like what they have done at Rockland MD [a large private clinic in Montreal]. They have built facilities and patients are coming, sent by the hospital, and it's paid by the hospital. So the hospital doesn’t have to invest in new operating rooms. It is done by the private sector but paid by the public sector, and why not? Some people are against that but they don't think about the patients. Those patients that had their operations are very happy to have that. And they didn't pay for that. It's more effective. One thing I have seen, and this was in a report from Australia, they are trying to separate the operating rooms for surgeries and operating rooms for what we call elective care -- not urgent. Like it is in Rockland, someone is an outpatient and there won't be an emergency coming in that will disturb the schedule or postpone any cases. If we have operating rooms and surgeons dedicated to do only elective cases, then the patient will know at 3 o'clock he will be operated on -- unless there are some complications. But usually [delays] are not because there are some complications but because an appendicitis is coming or whatever. We need to find ways to be much more efficient – this is the bottom line. Because we are spending a lot of money in our system, and we are not efficient enough. And there is room for that. We cannot solve everything with this but there is room to improve.

One of the other things you spoke about when you became president last year was that you wanted to tell the rest of Canada about the successful public prescription drug insurance program that we have in Quebec, because that kind of thing doesn't exist in the rest of Canada.

Yeah, not at the same level, at least.

What has been the reaction when you've discussed it with people across the country?

I'm very surprised, first, that people are not aware of that, that it exists in Quebec. It’s been there for 12 years at least and people are not aware of that. Some people are very in favour of that kind of system but some people are afraid, saying it will cost so much. Well, it depends, because you don't start from scratch. Like, some people have private insurance here in Quebec and the system lets them keep that private insurance. And it's the same for many people in other provinces. The problem is that some people are not covered. It's worst in the Maritimes. I've been trying to talk about that everywhere in Canada, and some people are picking up on that but they are so afraid of costs. But I still believe this is part of our system. What we have seen in European countries is that it is covered, at least partly, like it is in Quebec, by their healthcare system. And we are talking about the universal healthcare system, yes. They are covered for doctors and hospitals, but they are not covered for pharmacare, which is an important part. I've been talking about that, trying to push on that. I don't know where it is right now, but it's too bad that people are reluctant. And I know there is a cost to that but it might not be the cost they think starting from scratch and having 100% coverage from the government. That's not what we're talking about.

Another thing you've proposed in the past was a tax on junk food.

It didn't go that far. [Laughs]

Well, it was an interesting idea.

Yes, but it didn’t fly.

It reminds me of the tax on alcohol that Michael Kirby wanted to fund mental health care, which people also couldn't stomach.

Well, nobody took that and tried to do something with it. We've been talking about a lot of things but this one didn't fly.

Do you think the Conservative federal government’s inaction on health policy since it was elected in 2006 is because A) the political reality of minority government has prevented the Conservatives from doing what they’d like to do, or is it because B) the Conservatives have changed their position from the reformist one they used to advocate?

I think the answer is probably yes for both. Nobody is talking about healthcare at the federal level except for the H1N1 flu or things like that. But if we are talking about, let's say, wait times, they seem to say, “Well, this is a provincial thing.” They don’t want to be involved in that, but they should be involved. Because, first, they are paying a part of that, and they made some promises they would fix the system. They are putting money but things are not happening as fast as they should. It seems like there's no response. Nobody is talking about healthcare at the federal level except, as I said, for isotopes and H1N1 flu. Meaning that the problems we have with wait times? It seems that, oh, we have fixed that! Which is not true. And just remember the last [federal election] debate: there was one question in French, one question in English about healthcare, and that's it. It doesn't make sense. This is a big problem. And, you know, it's a provincial thing, but federal is involved and should be involved.

Was the disruption problematic from the CMA's perspective when the health minister job changed from Tony Clement to Leona Aglukkaq?

I would say no. I have had a few meetings with her. She is open-minded, and she is aware of some problems we have in remote areas. There was a good collaboration with the minister, but still we are waiting for involvement more than that. She will be at our general meeting next Monday.

I wanted to get your thoughts on the health reform debate that's currently going on in the US.

I don’t want to tell them what to do, of course, but I think the most important thing they have to do is to have universal coverage. That is the big drawback of their system now, universal coverage. Of course they have to work on the costs because their system costs about one-third more than our system and more than any system in the world. They have to work on defensive medicine, liability. This is a big issue in the United States, and I'm sure they need to talk about that. It's not on the forefront right now.

The current proposal in the US Congress is shooting for universal coverage, with a public insurance option but also with private insurance companies offering both necessary and supplementary health insurance. Would you prefer that instead of the Canadian one?

No. No. I think that we have a different approach. And they should do things differently than we do in Canada, because the starting point is not the same at all. Their starting point is the private insurance companies, and our starting point is a system paid by income tax. What I say to people in the States -- and I don’t tell them what to do, because you don't tell an important neighbour like the US what to do -- but what I have been saying is the system in the Netherlands could be implemented in the US. Their system is based on six private insurance companies. These companies are ruling the system, but there are some rules, and the first one is it is compulsory to be insured, universal coverage. No company can refuse a patient, like they do in the States. If one company takes a high-risk patient, there is some compensation between the companies because of that. And if the patient doesn’t have the money for a premium you have to pay, then the government will pay for you.

That sounds like the Massachusetts system.

Yes, but it is working. I know it's a smaller country than the US. When I was there I said, “Well, if I was an American, I would think about that.” But, you know, Obama said he will fix the system in one year. I said that. But I think he is much more powerful than I am. [Laughs] But it's something they could look at. The big discussion in the US is that people in the US don't want to have the Canadian system, and people in Canada don't want to have the US system, and probably they are right. It's not the way to go in either place.

What are your expectations for Dr Anne Doig’s presidency?

The mandate of the president is to be the spokesperson of the association and to keep on with the process that is going at the association, so it is not a stand-alone thing, the presidency. She will follow the project, and she's ready to do that. Because it's not a pet project I have or a flavour of the month for the CMA. We have put so many resources and time in that project that it won't end at the end of next week. That doesn't make sense.

What about the following year, when Jeffrey Turnbull will likely become president.

He will follow also. I have met him, and you may ask him, but he will not change the way we are doing things. It's not just the president. There is board, GC is giving us direction, and it's not the president that does everything. Of course, the president has his opinion but no, it won’t change. And he knows that.

Do you think it's possible anybody might challenge him in the election at the annual meeting this year?

It's possible.

Have you heard anything about that?

No. But it's still possible. In the bylaws, you have to wait until, I think it's Monday afternoon. I know that because I had that for myself. I was just waiting and, okay, nobody's coming, fine. But you don't know. By the rules it's possible to have someone. I don't mean that there will be, but it's still possible, so he's not elected yet.

When we spoke when you became presidnet, you told me you were nervous about having to speak in English in front of crowds. Has your English improved with practice?

Yes, I think so. I've been practising, but I'm still a francophone, but I think I can now give some presentations and interviews in English. It's working better. I was told to improve, to take lessons with media to improve English and to learn to play golf. But I didn't do the last one. I didn’t have time to golf. It was a very busy year.

How do you feel about finishing your job as president and going back to your radiology clinics in Montreal?

Well, that’s the fate of a president. You become past-president and the phone stops ringing the next day. Well, maybe for a few things. But that's the way it is. If you are aware of that, you get prepared, and that’s it. I know the week after I won’t have 25 emails a day. It's a big change.

Are you planning on staying involved in medical politics after your year as past-president?

I have been elected as a representative of Canada to the World Medical Association, so I am there for at least three years. That was at the last board meeting. I'll be the observer for a year and a half and then the full member. So I am going to India in October to the WMA meeting. Besides that, first I have one year as past-president and I surely want to be involved. Maybe we'll have a committee for the implementation of that framework, and I surely want to be involved in that because I've been doing quite a lot of work with that and I think I could still play a role.

One last question. I know you’re a big Formula One racing fan. Were you disappointed that this summer Montreal didn’t host a race for the first time in over 20 years?

Oh, yes. But I hope next year it will be back. Now I live downtown in Montreal and I've spoken to many people around, and the people – you know, owners of restaurants – they say this is an important business for them, the F1 race here in Montreal. And they are expecting that to come back next year. For me it's not the same but I like that. And of course I was very sad that we didn't have that this year.

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  1. that lung21 March, 2012 10:00 PM

    The Canadian Medical Association has reported some new numbers on locum use from the 2007 National Physician Survey.According to the survey, 29% of doctors wanted to get a locum to come in and cover their practices for a time but were unable to find someone willing to do so. Unsurprisingly, therefore, nearly half of physicians said they were dissatisfied with the availability of locums."As a profession we should be worried about that," said CMA president Dr Robert Ouellet.