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What do the CMA's members want?

Yesterday's CMA Members' Hour was closed to media so Canadian Medicine can't provide you with any special insight about the debates on following list of topics that the CMA says were discussed, but here's the list nonetheless:

  • the financial deficit at CMAJ
  • doctors who lose their medical association benefits because they move to a new jurisdiction
  • the need to seek patient involvement and support when the CMA is seeking changes within the health care system, perhaps via a patient advisory board
  • the development of a pension plan for physicians
  • the lack of a remuneration for physicians who take on teaching duties
  • steps the CMA is taking to help physicians use electronic medical records
  • the need for the CMA to continue promoting physician health.
What Canadian Medicine can assure you of is that none of these topics are going to disappear in coming years, and will likely be revisited today during General Council motions or in coming years.

Doctors celebrate Canada Health Act's 25th anniversary

Decades-old federal legislation is not typically feted with impassioned speeches, popcorn, cake and sangría. The , however, is not a typical piece of federal legislation.

On Sunday night in a movie theatre in Saskatoon – smack dab in the middle of the place where the first Canadian medicare system took shape under the leadership of Greatest Canadian Tommy Douglas – well over a hundred physicians, nurses, politicians and citizens gathered to celebrate the 1984 law culminating the years and years of incremental progress that led to the single-payer, universal Canadian health-insurance systems now in place in every province and territory.

The 25-year-old legislation's birthday party was thrown by an activist group of physicians known as Canadian Doctors for Medicare, which has set up shop here in Saskatoon in large part to act as a counterweight to the Canadian Medical Association's reformist lobbying.

A large audience turned out to hear keynote speeches given by Canadian Doctors for Medicare chair Dr Danielle Martin (left) and by former Saskatchewan premier and federal health commission leader Roy Romanow (right). Local and national politicians and medical leaders, including new CMA president Anne Doig, NDP MP Judy Wasylycia-Leis, Canadian Federation of Nurses Unions president Linda Silas and others were in attendance.

Mr Romanow's speech began with a recitation of the history of the creation of the Canadian medicare system. He took a few shots at the Conservative federal government, including some pointed comments about Prime Minister Lester B Pearson's accomplishment of negotiating a bill creating universal medicare through Parliament when he was in command of a minority government.

Mr Romanow appealed for government to introduce a universal pharmacare plan, to insure Canadian patients against catastrophic drug costs. He also urged the addition to medicare coverage of home care and palliative care.

Continued vigilance and lobbying will be required to protect and improve Canada's medicare system, Mr Romanow said. “A great responsbility rests on all of us who believe in medicare.”

The ongoing medicare fight represents something more than a battle for the nation's healthcare system, he said. It is a “canary in the coal mine” -- the first point at which the federal government's willingness to stand up for the protection of Canada's social support system is being tested, Mr Romanow said. “We need today an active federal government, to create a functioning, not a warring, federation,” he said, warning against decentralization. “We do not feed a federal government that cedes issues to the provinces and special interests.”

Dr Danielle Martin followed Mr Romanow's speech by arguing that evidence has shown publicly delivered, not-for-profit healthcare to be cheaper and of a higher quality than private, for-profit care. Another advantage, she said, can be seen in the difference between administrative costs in the healthcare systems of the United States and Canada. In the US, administrative costs represent 31% of health spending; in Canada that figure is just 1.3%.

Dr Martin also argued that medicare has not only served patients well but has also been beneficial financially to physicians. In the 1970s and 80s, she said, budget cuts pushed doctors to charge patients directly for care. The Canada Health Act relieved doctors of that burden and instituted a national system that established how physicians would be paid, which in turn, Dr Martin said, led to improved collegiality among doctors because there was less inequality in pay for similar work.

But Dr Martin's goal is not simply to prevent change. She believes, like Dr Doig and Mr Romanow and many others, that medicare must adapt with the times. Dr Martin's goal is to make sure that those adaptations don't threaten the principles that made medicare so valuable to Canadians in the first place. “A better medicare is possible,” she said.

Before the giant birthday cake was cut and the party began, Dr Martin encouraged physicians to think fondly of the 25-year-old legislation. “This,” she said, “is an opportunity for the medical profsesion to realize the Canada Health Act has served us well.”

As attendees got ready to leave, one young med school graduate stood up at a microphone to invite people to her friend's parents' house to drink sangría and continue the conversation about health policy, proving once again that the Canada Health Act truly is an unusual piece of legislation. As Dr Nuala Kenny, the well-known retired Nova Scotia pediatrician and bioethicist, said: just compare the civil tone of Sunday's Canada Health Act discussion to the wildly acrimonious attitudes we've seen on television at the health-insurance reform town-hall meetings taking place now in the United States.

Photo (Danielle Martin):
Photo (Roy Romanow):


Economic turmoil is hurting Canadians' health: CMA survey

Twenty-three percent of Canadians say the recession has affected how they take care of their health.

That disturbing information -- that the economy's problems are causing pain not just in our portfolios -- was revealed in new survey results published by the Canadian Medical Association Monday in Saskatoon in the (PDF).

The survey showed that the "economic downturn" (as the survey euphemistically calls it) has had dire results for Canadians' health.

  • 25% of Canadians cancelled or pushed back a dentist's appointment
  • 16% skipped meals
  • 32% cut back on their food budgets
  • 14% delayed or skipped buying some prescription medications
  • 23% have slept more poorly
  • 22% chose not to join a new sport or recreational activity
  • 10% cancelled or delayed a doctor's appointment
"Governments have ignored tackling the tough issues facing our health care system," outgoing CMA president Dr Robert Ouellet said in a release. "There is a mistaken impression that health care is somehow insulated from today's harsh economic reality. Our polling results show -- that's just not the case."

Dr Ouellet told reporters on Monday the survey results surprised and concerned him.

The stock market's tumble has also affected the Canadian Medical Association's financial health. The organization has trimmed more than $1 million from its operating budget after it saw its investments shrunk by the recession.

Jeffrey Turnbull to be acclaimed CMA president-elect

The deadline has come and gone for a challenge to be mounted against Ottawa physician Jeffrey Turnbull's nomination to be the Canadian Medical Association's next president.

Under CMA election rules, a member could have chosen to mount a challenge from the floor of the General Council assembly. No challenges have been attempted since Dr Jack Burak attempted but failed to defeat BC nominee Dr Brian Day in 2006.

is an internist and chief of staff at the Ottawa Hospital. He has been the medical director of the Ottawa Inner City Health Project, which provides not only medical care but also doses of alcohol, to homeless men in the city.

The campaign Dr Turnbull ran for the presidential nomination made clear that his politics differs from those of Drs Brian Day and Robert Ouellet, who have both urged loosening restrictions on private healthcare funding in the Canada Health Act.

You can read more about Dr Turnbull and his nomination in this Canadian Medicine piece from March.

Dr Turnbull will serve as the organization's president for one year, beginning next August, after Saskatoon FP Anne Doig's term ends.

Photo:

In speech to CMA, Aglukkaq skirts reform issues

In an address to the Canadian Medical Association on Monday morning, federal health minister Leona Aglukkaq spoke about crucial topics including the radioisotope shortage, the H1N1 flu pandemic and health promotion.

But Ms Aglukkaq did not appear eager to respond to the CMA leadership's increasingly loud call for the government to implement major health-system reform and to reconsider some of the restrictions on private healthcare funding imposed by the 1984 Canada Health Act.

Considering she was appearing at a conference titled “Health Care Transformation: We Can All Do Better,” doctors in attendance might have expected that Ms Aglukkaq would make at least passing reference to the state of health policy reform in Canada. CMA president Dr Robert Ouellet even appeared to invite her to do so when he introduced her. “You join us at a time of considerable change,” Dr Ouellet said. “You are also no doubt aware of our discussions that will take place here in Saskatoon about our efforts to transform the healthcare system to put patients first.”

But, apparently mindful that her audience for this morning's speech would be reported on well beyond the walls of the downtown Saskatoon conference hall where she spoke to the nation's senior physician leaders, Ms Aglukkaq chose to focus instead in her speech on the two medical crises that have recently grabbed the public's attention.

Ms Aglukkaq spoke broadly about what is anticipated to be a significant resurgence of the pandemic H1N1 flu virus in Canada this fall and winter. She summed up the government's recent efforts to disseminate information and work with pharma company GlaxoSmithKline to produce a vaccine for this November, and she encouraged physicians to consult clinical guidelines available at www.fightflu.ca. (For more on the federal government's preparations for the H1N1 flu's second wave, don't miss Parkhurst Exchange's wide-ranging Q&A with the nation's chief public health officer Dr David Butler-Jones, set to appear soon in the magazine's September issue.)

At one point, perhaps forgetting she was standing in front of a room of perhaps a thousand experienced clinicians, Ms Aglukkaq decided to provide the public with some of her own medical advice: wash your hands, she said, cough into your sleeves, and stay home if you're ill.

A few minutes later, however, her faltering voice seemed to signal that she could use some clinical attention herself. “I hear there's a doctor in the house,” she joked to a smattering of polite laughter. This audience has heard that one before.

On the topic of the radioisotope shortage – which, as you will recall, is the result of unanticipated repairs that shut down the Crown-corporation-owned Chalk River nuclear facility in Ontario – Ms Aglukkaq began with a simile to demonstrate her familiarity with the subject. “As you well know, medical isotopes cannot be stockpiled,” she said. “As a result, distributing them is like delivering ice cubes from door to door on a hot summer day.”

Alternatives to the technicium-99 produced at Chalk River are now being researched, Ms Aglukkaq said, and the long-term plan is still to get Chalk River's production up and running again. (The estimated date when the plant will be producing isotopes again has been pushed back several times, most recently to spring 2010.) Another part of the long-term radioisotope solution, she said, is to better coordinate radioisotope production shutdowns with the other providers overseas, such as the ones in the Netherlands, South Africa and elsewhere. Overlapping shutdowns have proven to be problematic this summer.

During the Q&A with CMA members after Ms Aglukkaq's speech, she was asked by Canadian Society of Nuclear Medicine president Dr Christopher O'Brien whether the additional costs incurred by the provinces buying alternatively sourced radioisotopes would be covered at all by the federal government. Ms Aglukkaq replied that several provinces have raised the issue with her and that she plans to discuss the matter with the provincial health ministers at a meeting in Winnipeg next month.

Ms Aglukkaq also acknowledged the substandard health conditions seen in First Nations, Inuit and remote Canadian communities. She spoke of the need to ameliorate what are called the social determinants of health, such as education and housing, and quoted Benjamin Franklin: “An ounce of prevention is worth a pound of cure.”

Ms Aglukkaq concluded her speech – still with no mention of the Canada Health Act or health policy reform or the CMA's “transformation” agenda – by recognizing the medical community's altruism.

“Just as your decision to enter medicine wasn't based on money, neither was my decision to enter politics based on prestige or power," she said. "The determining factor in your decision was most likely the same as it was mine: the real chance to make a difference and be rewarded by the immeasurable satisfaction of saving lives and helping change lives for the better. When faced by challenges such as most people are today, it is important for us to remember this and to realize the time for this ambition is now.”

Photo: Health Canada


Does the CMA have a conflict of interests on electronic medical records?

Try to reconcile the following two facts:

1. Though some consolidation in the Canadian electronic medical records market is not necessarily a bad thing and may in fact be necessary, healthy competition between software companies in that market is important for the development of the industry and for both the continuing improvement of the products offered to physicians and to keep software prices down.

2. One of the country's leading (and growing) EMR software providers is Practice Solutions, which is owned by a Canadian Medical Association subsidiary company called CMA Holdings Incorporated. CMA Holdings, like just about every other investor, had a rough year; its contribution to the CMA's operating budget was slashed in 2009, prompting $1.003 million in budget costs at the CMA. Meanwhile, Practice Solutions, from all signs, is going strong. According to a report from CMA Holdings president/CEO Brian Peters in the CMA's 2008-09 Year in Review report, Practice Solutions has managed to grab a 47% share of the EMR market in Ontario and is expanding into Alberta and Saskatchewan now.

Now consider this. On the one hand, Practice Solutions's business success should come as good news for CMA members at a time when CMA Holdings could use the help. But, on the other hand -- keeping in mind fact #1 above -- the rapid growth of one EMR provider at the expense of a more diverse market may be a dangerous sign for CMA members who use electronic records in their offices.

These two facts may not be irreconcilable, however. One clue came this morning at the CMA's General Council meeting in Saskatoon when one member as well as new president Dr Anne Doig pressed federal health minister Leona Aglukkaq to release a promised $500 million in new funding for Canada Health Infoway, which funds provinces' initiatives to encourage and incentivize doctors to adopt electronic records. If doctors can convince government to spend taxpayers' money to pay for their record-keeping systems, then why should they care what the software costs?

Monday morning reading in Saskatoon

SASKATOON -- Hello from the CMA annual meeting, Canadian Medicine readers. We'll have plenty more coverage coming up later today, but in the meantime you can read what some other reporters are writing.


The CMA's new president, Anne Doig, is featured in a profile by André Picard. "I see my patients not getting as good of care as they could and should and I don't find that acceptable," she told him. "But I can't just sit in my office and grouse so I decided to act."

The Canadian Press's Jennifer Graham takes a look at Dr Doig's call for health-system overhaul. "We all agree that the system is imploding, we all agree that things are more precarious than perhaps Canadians realize," Dr Doig said. Ms Graham also discussed the anticipated second wave of the pandemic H1N1 flu with Dr Doig.

Local reporter Jason Warick previewed federal health minister Leona Aglukkaq's speech to the CMA General Council, scheduled for this morning. She plans to discuss the radioisotope-shortage crisis and the H1N1 flu.

The Toronto Star praises Dr Doig for what the paper's editorial board considers to be her break with the activist pattern established by Brian Day and Robert Ouellet over the last two years. "With new leadership, the CMA has an opportunity to put its considerable resources toward seeking improvements within the public system."

Konrad Yakabuski cautions Canadian politicians that healthcare reform here could be as difficult to accomplish as it's proven to be in the United States over recent years, and suggests that alternative models of physician compensation should be on the table. [The Globe and Mail]

And don't forget to read Canadian Medicine's Q&As with outgoing president Robert Ouellet and new boss Anne Doig, published today.

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 , 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.

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.