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Monday, August 17, 2009

New CMA president Anne Doig urges medicare repairs

SASKTOON -- Anne Doig, a Saskatoon family physician and longtime medical leader, was elected to the position of Canadian Medical Association president last summer in Montreal, but she will officially take over for Dr Robert Ouellet this week, here in Saskatoon. Dr Doig's got a pedigree when it comes to medical politics: her father was among the physicians who opposed NDP premier Tommy Douglas's creation of medicare in 1962, and her brother Chip will be the 2009-10 president of the Alberta Medical Association.

Even more impressive than the depth of her experience in medicine and health policy is the fact that Dr Doig has accomplished what she has in those areas while also making time to have six children, own a grain farm, swim competitively and stay involved with swimming tournaments.

Before the beginning of this year's CMA annual meeting, she spoke to Canadian Medicine about health-insurance reform, the Canada Health Act, abortion (sort of), swimming, and more.



SAM SOLOMON: What do you hope to achieve as president?

ANNE DOIG: I think I’ve already laid out some of that in the material that is circulating. Essentially what this boils down to is taking the information that Dr Ouellet has gathered, learning from GC [CMA General Council] what the membership thinks about that information and the current situation, going out to the membership to ask what we should do -- and, parenthetically, some of that work is already being done through an online forum with Asklepios -- because we need to know what members think needs to be done. I think we need to improve effectiveness and efficiency. What do we think can be done to improve the system? That helps us when we’re asking government to look at new funding models and to make hard decisions about what the public system is really willing to cover. At the moment, government -- and I use that in the lowercase-“g” sense, because it’s governments of all stripes -- all of them hide behind saying “We have the best medical system in the world, and medicare is being threatened!” This is not about medicare being threatened. This is about making it work over the next 50 years. It’s done a reasonable job for 50 years but it is not sustainable.


Can you give some specifics on the kinds of effectiveness and efficiency improvements you have in mind? I know Dr Ouellet mentioned Advanced Access.

He stole my example! But Advanced Access is not just limited to primary care. It is not just about family docs. For instance, there is a urology clinic here in Saskatoon that uses it. The principles of Advanced Access do apply, can apply, to specialists' offices. And one of the hidden inefficiencies in our system – and I deliberately use the word “hidden” -- is no one is quantifying and talking about things like wait times between my decision to refer a patient for a non-urgent or mildly urgent – if you know what I mean -- to a specialist and when that specialist actually sees the patient. For example, if I see an elderly patient in my office this week, as I did on Monday, and I make an initial referral to have one of the orthopedic surgeons see her about changes of arthritis in her hip, thinking that somewhere down the line she might be a candidate for a hip replacement, it's going to be, who knows? Six months? Nine months? 12 months before that patient is even seen? Then she gets on the list to have whatever diagnostic tests need to be done over and above what I've already done, and then she gets on a surgical wait list. And no one is out there measuring, because it really can't measured because we have no way of capturing that data – you know, what's that timeframe between family physician assessment and the specialist? How can we help the specialist to improve management in their offices to match the improvement that family physicians and trying to make?

There are a whole different set of access problems for emergency care, of course.

And of course what it's resulting in is a domino effect of everything. You've heard about the domino effect of patients not being able to be discharged appropriately from hospital, so that plugs the acute care beds, so that then puts pressure on the emergency room and you can't admit patients. There's another domino. Another domino is the domino of what happens when doctors know their patients are waiting way too long for specialist consultations: they end up pushing the urgent button as a mechanism to get their patients seen more expeditiously. There are things that we as physicians can try to do. And some of these are answers to a fundamental shortage of human resources. We don't have enough bodies on the ground so we have to find a way to make the bodies that are available to us able to do their jobs more effectively, and effectiveness is the second thing I want to talk about. That's where the quality agenda comes in. So, are there things we can do that would improve the quality of care that we are offering? There are organizations like the Saskatchewan Health Quality Council – and I know there similar bodies for the other provinces – that are looking at those questions and saying, “Here, look, here's an example in post-miocardial infarction care where we can give you some specific pointers on which interventions and what to do to be effective in looking after these patients.” Certainly in primary care we have models out there for chronic disease management, for hypertension, for heart failure, for diabetes management. Those are quality initiatives, and if physicians are able to take the time to step back from their own practices and look at what they are doing and implement some of these suggestions, then that's another way of improving the quality of care.

You have mentioned more than once, I believe, that you’d like to de-emphasize the public-vs-private aspect of the health reform question.

It's a surrogate for scaring patients, you know? I mean, let's tell people [sarcastically] their healthcare is being threatened because the doctors are bad people and want to bring in the private sector. That's simply a scare tactic. We have to engage the public to say, “Look, folks, here are the real costs, here is the real situation. You want your care. How do you want it paid for?” And of course the cop-out answer is “I always want it free and I don't want to pay anything.” Sorry! We all know that's not sustainable. And we all know that models in other countries – wherever we're looking at things where there's a single route, then those models are failing.

What other routes do you want to see? Supplementary health insurance?

I think we have to look at some form of diversifying the revenue streams to pay for the care people are getting, while at the same time improving the product that they are getting, so that we can lower costs by improving some of the product. But at the same time we have to find additional dollars. So for example Dr Ouellet will talk about models in other countries where there is private insurance but it's mandated by government and everyone in the country has insurance. It wasn't one of his countries from the European tour but Israel is an example of that kind of model. In that model the government picks up where the insurer -- or where the person is not employable or not employed, then government steps in and pays a premium so that people are always insured.

Do you believe, like Dr Day and Dr Ouellet, that the Canada Health Act’s restrictions on private insurance are detrimental to the healthcare system?

I think the whole point is the principles that are articulated in the Canada Health Act – you know, principles around access, principles around affordability, principles around transportability, that kind of thing – those are basic, fundamental principles. The principles may not need not change. But where the Act has strayed into being prescriptive about process, perhaps government does need to look at that and say, “We revised legislation for every other type of legislation that covers benefits or services, or even the rules of road.” I mean, all those things get changed over time -- they're not static. Why is the Canada Health Act seen as a static piece of legislation? Its principles may be static, they may be inviolable, they may be principles to die on. But how we interpret that in the context of the current reality is, I think, open to debate.

There is almost daily stream of fear-mongering in the United States about the evil Canadian healthcare system with its horrific wait times and Communist rationing. It seems like that can't help but to have some effect on how Canadians feel about our system in some way. Do you think the CMA has a role to play in countering the criticism from the US?

I don't think the CMA has a role to play in engaging in the US debate.

I guess I mean as it pertains to the Canadian system. There have been all sorts of accusations from US groups recently about what is wrong with Canada's model or how we're rationing care for the elderly, etc.

Well, I have to tell you parenthetically that one of the things that the CMA wants to see improved is the availability and provision of care for those who require longterm care. We are acutely aware that the provision of longterm care is inadequate in Canada. So part of my point is it really irritates me when inflammatory rhetoric is used instead of people being able to engage in debate. There is a problem in longterm care in this country. People need to wake up and smell that coffee, and the CMA is certainly not going to be shy in giving that message to the public. However, what this whole US thing says to me is, you know, it’s the two-headed hydra. The physicians in each country are looking at the systems and saying, “You guys, the system is about to implode. It's going to fail.” And the US guys are saying, “Oh, my god, we don’t want Canada.” And Canadians are saying, “We don’t want the US.” Okay. Both of us need to sit down, each in our own jurisdictions, and come up with something that works for our citizens and for our doctors, and go forward. I mean, I think one thing that the US finger-pointing has done is it's made some Canadians who were complacent – you know, they were content to sit back and think, “Oh yeah, I've got the best healthcare system in the world” -- maybe they're realizing that, oh, maybe it isn't. And people who individually have experienced things that are not quite right, people who have experienced long waits, people who have been sent home with services -- they may have thought they were individuals and something bad happened to them but, overall, the system is good. Maybe some of those people are now beginning to realize the problems are far more systemic than they thought.

This is a question that's a bit less policy-based. You're a family physician and I know that you've been doing obstetrical services for years, and you've been a lay speaker in the Catholic Church for years?

Lay reader. Yeah, I'm one of the people who just gets up and reads the scripture passages in services.

It's interesting to me that it's in the Catholic Church and I wondered what advice you give to patients who you provide obstetrical services for about abortion.

Ha!

Whether those two things are...

Oh, boy. Okay. You know what, I can't answer that question in the context of a discussion about my CMA presidency. That's just not on.

Why?

Because dragging my personal, religious or moral beliefs into a discussion where I am being interviewed as the incoming CMA president, no matter how you write that it's going to have implications for the CMA. And I'm sorry but that's just not on.

It seems like a fair question to me given that abortion is a policy issue.

You know what? It's a fair question to ask me personally. It is not a fair quesiton to ask me in the context that you asked it. You asked it as what advice do I give my patients. I can tell you what the ethical obligation of a physician is. The ethical obligation of a physician is to ensure that patients are given all of the available information that they need to make a decision in their personal circumstances about their medical condition. That is the ethical obligation of a physician.

And you don't think it's pertinent to CMA policy what the president's beliefs are on such an important issue?

You put it in the context of a policy question and I reflected to you what the CMA policy is. The CMA policy is that all physicians in Canada behave ethically and the ethical physician will make sure patients are provided with information and services they requre in a given context. That's the ethical obligation of a physician. That's the policy that you asked about. My personal beliefs do not enter into an ethical decision and they do not enter into my role as CMA president.

Okay, let's move on. Robert Ouellet was very interested in growing the CMA’s membership in Quebec. I wondered what your thoughts are on that and also how your French is. I know for him, coming from Quebec, he was concerned about his English.

If I can improve my French as well as Robert has improved his English in the next year, then I will have accomplished something. My French is good. I can read from French aloud and I can read written French reasonably well with comprehension but I'm slow. Where I fall down is on dialogue. So if you ask me a question in French, I can't really respond in French with the ease and flow I should be able to do. That being said, definitely I intend to make my speeches in Quebec as much in French as I can, and that's going to be a lot of hard work for [CMA media relations manager] Lucie Boileau and for me as well in terms of practising. It's very, very important.

I suppose it's an advantage that you'll have Dr Ouellet as a resource.

I'll have him as a resource but I think it's also important that the current president has presence in all of the divisions in the CMA. I will absolutely lean on Robert for support and I will absolutely appreciate whatever support he's able to give me, but the poor man's done his stint. He's worked very hard this past year and I think it's important for francophone Canadians to see that those of us in so-called English Canada are in fact attempting to reach out to them and wishing to be colleagues with them, wishing to be collegial.

And for the last question, I wanted to follow up on something we spoke about last year, when you told me one of your sons had qualified for a national tournament in competitive swimming. How did that go?

He qualified for Team Sask and is swimming in Canada Games.

And are you still involved in the sport? Are you officiating?

I will and actually so will his dad. I will be one of the major officials and his dad will be one of the minor officials for swimming at Canada Games. We're going down to Charlottetown after GC is over.

7 comments:

  1. Well done, Anne!

    I think it's wonderful that she can be so candid, yet professional, and also steer back to the original issue at hand (especially well done on the response to the abortion issue!)

    Looking forward to see what Dr. Anne Doig has in store in terms of ideas to improve our healthcare system!

    J, from Toronto, ON

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  2. Anne, what are you afraid of? You are Catholic, your belief system makes up who you are. You have 6 children that you are proud of. Why not speak candidly and honestly about your views on abortion. You sure didn't pull any punches on the other controversial issues. What is wrong with discussions on abortion? As a Catholic you are obliged to defend the most vulnerable- yes even in the workplace. Wade into the deep, be not afraid! Sound familiar?

    Jeff Gunnarson
    Cambridge, ON

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  3. The Right Wing American idiot, Larry Elder, was on tv misquoting Dr. Doig's "imploding" comment. It's astonishing what people will say and do for money.

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  4. I saw that comment from Elder, and that's what brought me to this blog. Well at least I'm not idiotic enough to take these talking heads at their word.

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  5. No, Dr. Doig actually said Canadian Healthcare is "imploding", but not specifically here. She states such in the Canadian Press, and that has been quoted around the world.

    Since that embarassing quote, the Canadian Press has since removed all trace of that specific article.

    So much for the public's "right to know" in Canada, eh?

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  6. Orwell's News at National Post:

    Kamchatka, peninsula
    September 1, 1983


    Soviet heat seeking missile flying on a peaceful mission over Russian territory was hit in midair by a Korean jumbo jet 747spy plane with 269 American spies on board. There was no loss of Soviet life in that incident but the missile however was completely destroyed.

    http://www.nationalpost.com/news/story.html?id=2655329
    Doctors damaged by medical errors, experts say
    Meagan Fitzpatrick, Canwest News Service Published: Monday, March 08, 2010

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  7. Alexander Franklin,TorontoJune 12, 2010 at 7:10 AM

    Lots of words; few facts. A CMA PRESIDENT- ELECT should be paid by CMA to get a MBA or at least a MHSc.

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