Canadian Medicine

One of the great untold stories of the Canadian healthcare system in the 21st century is the failure since the 2003 Toronto SARS crisis to put in place the necessary precautions to prevent another public health disaster.

That failure is seldom raised in public -- pandemic preparedness, like or , is one of those things the importance of which only become fully apparent when they fail -- and has been consistently underestimated by senior federal officials.

Now, three new reports published over the last month have forced the debate into the public eye, and their conclusions are worrying.

"A LEGISLATIVE FAILURE"
An (PDF) appearing online in the Canadian Medical Association Journal (CMAJ) last week called the state of Canada's pandemic planning "a national embarrassment." Amir Attaran, the Canada Research Chair in Law, Population Health and Global Development Policy, and the CMAJ's editors pull no punches:

In a deadly epidemic, Ottawa’s laws to protect Canadian poultry are stronger than its laws to protect Canadian people. Parliament must urgently legislate a way past the jurisdictional schisms before the Auditor General reminds us — again — that it is dangerously overdue. Or worse, before a deadly epidemic demonstrates our failures.

The country's main failing on pandemic planning over the last decade, the editorial says, is the absence of an agreement between the provinces and the federal government to share "epidemiologic information." Only one province -- Ontario, "humbled by the SARS epidemic" -- has agreed to share information about infectious diseases.

The lack of information sharing was brought up earlier this year, as well, in the Auditor General's 2008 report to Parliament. devoted an entire chapter to the problems with the Public Health Agency of Canada's surveillance of infectious diseases. That chapter's conclusions are a grim recounting of much of what many Canadian public health experts already know:

[L]argely because of gaps and delays in the data supplied by its partners and because of weaknesses in its informal data sharing methods, the Agency may not be able to systematically analyze and report information on public health threats. [...]

Given that the threats from infectious diseases are rising, Canadians expect the Agency to ensure that it is adequately monitoring important public health events to minimize the potential risks to their health and the economy. Despite some important accomplishments, the Agency has not satisfactorily addressed many of the concerns raised in our previous audits, some of which were evident during the SARS crisis.

A GLOBAL CONTEXT
In late May, a team of researchers from Australian National Univeristy in Canberra released a , in the online journal Public Library of Science One, that compared pandemic planning for primary care in Australia, New Zealand, England, the United States and Canada.

As you can see from the table below, Canadian provinces fared well on some aspects of planning, including influenza care, infection control and public health surveillance. But Canada compared poorly with the other four countries when it came to non-influenza care and, importantly, in "linkages between health systems" -- just as the CMAJ editorial and the Auditor General's report pointed out. Here are the numbers from the Australian comparison (full table available ):



FEDERAL DENIAL
In what is beginning to look like a pattern when it comes to the role of health research on public policy, the federal government remains willingly oblivious to the looming threat of the sorry state of public health surveillance communication between jurisdictions.

Federal Health Minister Tony Clement, who was the health minister of Ontario during the SARS outbreak and would therefore seem well positioned to recognize the danger of the current situation, nevertheless maintains that Canada's readiness to respond to a future pandemic has vastly improved over the past five years.

The effect of the federal government's refusal to acknowledge -- exposed domestically by the Auditor General and the nation's most influential medical journal, and now internationally as well -- has been to alienate some of Canada's physicians and public health experts. Take, for instance, the tenor of this question posed to Mr Clement :

Mr Clement, I'm a dedicated, proud, but not twice foolish, Canadian doctor with a family of four, who stayed and fought through the SARS epidemic and lost a close colleague and friend, Dr Nestor Yanga. What provisions has the federal government provided in the event medical people go down in the fight against the pandemic bird flu when it hits, like Dr Yanga did? Personally I don't think we, in Ontario, are anywhere near prepared and next time I plan to take a 'holiday' from my office at that time as do many other physicians I have spoken with.

- Dr Paul Stephan, family physician, Thornhill, ON

[Mr Clement's response:]
Look, the fact is whatever hits us next, there'll be some aspect of it for which we will be unprepared — that's the nature of the pandemic. If we were prepared for the pandemic, the pandemic wouldn't arrive, it would be strangled at its source. But are we better off than we were in January 2003, five years ago, a month and a half before SARS emerged? The answer is most definitely, yes, we are better off.

The majority of the evidence -- in stark contrast to Mr Clement's positive spin -- appears to show that while we may be better off than we were five years ago, we are nowhere near prepared for the next threat.


Image: Patel MS, Phillips CB, Pearce C, Kljakovic M, Dugdale P, et al. (2008) General Practice and Pandemic Influenza: A Framework for Planning and Comparison of Plans in Five Countries. PLoS ONE 3(5): e2269. doi:10.1371/journal.pone.0002269 (available free online )

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A new American study has introduced some of the most potent seeds of doubt to date about the much-heralded Advanced Access scheduling method that is just beginning to achieve a measure of popularity in Canada.

In "," published in this week's Annals of Internal Medicine, three US researchers found decidedly mixed results for medical practices that attempted to switch over to Advanced Access scheduling (also called open-access scheduling).

GAINS AND LOSSES
Of the six practices examined in the paper, five saw huge gains in access almost immediately. "The 5 practices achieved substantial improvements in access, as measured by time to third available appointment, during the first 4 months after implementation. The average time to third available appointment decreased from 21 to 8 days for short visits and from 39 to 14 days for long visits."

But those improvements didn't last. Here were some of the results:

• Two years after moving to Advanced Access, the practices' average time to the third available appointment for short visits jumped from eight to 11 days, and up to 29 days from 14 for long visits. Two of the practices ended up with longer wait times than they had before they changed their scheduling systems.

• No-show rates, which are commonly thought to be reduced significantly by Advanced Access scheduling, remained steady throughout the two-year study period.

• Staff satisfaction improved in some of the practices after the switch to Advanced Access; not so in others, however.

• Patient satisfaction -- key to any scheduling change -- didn't see an improvement overall.

As if the authors' failure to verify previous studies' glowingly positive results on Advanced Access scheduling weren't enough, they also question the validity of other researchers' claims:

"Nearly all the [previous] studies have important methodological limitations (many of which our study shares), including no statistical testing, limited access-to-care measures, lack of concurrent control groups, small sample size, and inconsistent methods. Among the few studies that assessed outcomes beyond access to care, open access had mixed effects on patient satisfaction (2 of 5 studies reported improvement), staff satisfaction (1 of 2 reported improvement), and no-show rates (3 of 6 reported improvement). Our results add to this literature and raise the question of whether open-access scheduling truly leads to the ancillary benefits that advocates have proposed."

The researchers admit that their study may have been flawed -- "barriers" they hadn't accounted for might have caused the scheduling changes to fail, or the location of all the practices in Massachusetts might have biased the data somehow -- but the scent of failure is powerful nonetheless, and that should be disturbing to the many Canadians who have staked their practice revenues and their reputations on Advanced Access.

THE CANADIAN CONTINGENT
I wrote about several such doctors (one, Kishore Visvanathan, has been chronicling his urology group practice's struggles with implementing Advanced Access on ). And this April, I wrote about a spreading the Advanced Access gospel across Saskatchewan. "It's a tough transition -- very challenging," Catherine Tantau, a nurse who helped develop the theoretical and practical background for Advanced Access, told me. "But once people see what is possible and experience improvement in their day -- good grief, who would want to go back to practising with all the obstacles and burdens they have?"

But after the appearance of this new Annals of Internal Medicine paper, it seems that Canadian doctors may have to exercise more caution than some of the proponents of Advanced Access had initially anticipated. The new paper is far from a death knell for the same-day booking movement -- but it's a serious warning that Advanced Access is not the panacea it has sometimes been made out to be.


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There's a high chance the next patient who walks into your office has been researching their diagnosis on the internet and fretting over what they've found.

Roughly 62.5% of your patients Google their symptoms before stopping by the clinic, according to published mid-April in the journal Arthritis and Rheumatism.

SHY GUYS
But of those patients only 20% will discuss their concerns with you. The others, the study discovered, say they'd rather not come off as challenging your authority.

However, the research also found that when patients do bring up their concerns, both they and their doctors feel more satisfied with the visit.

M Cameron Hay-Rollins, the study's lead author and an assistant professor of anthropology at Miami University, suggests taking a couple minutes to ask patients what they've researched and guide them to the best information online.

VIRTUAL VENTURES
If patients are already on the web digging for information, doctors should join them and lend a hand, suggests , a pioneering Canadian FP, who is working to improve doctor-patient communication using the net (he's also featured in an article about 'block fees' this month in .)

Early this year Dr Foggin and his patients helped beta test the CMA's web portal, which has online applications to monitor chronic disease and private email services so patients can contact their doc directly. The system could be used to quickly dispel any suspect information patients have gleaned online and discuss their symptoms.

INNOVATIVE APPROACH
One of most interesting aspects about Dr Foggin's approach, though, is that patients who use the service have begun paying him a block fee for this direct access. "Patients have been receptive and realize that my time is valuable," he says.

Just last week, he was preparing to send out 600 letters offering patients varying degrees of online support. For him to monitor chronic disease using online tracking tools will cost about $50 or $100 for a family package. For more advanced services including 15 online interactions, disease tracking and refills he'll charge $129 annually.

"My patients feel a connection with me that they haven't had before," Dr Foggin enthuses. "It's brief, but it's me, and I can control my interaction."

Photo: A still of blood pressure tracking
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Dr Vincent Lam (right), the Giller Prize-winning author of the 2006 short story collection Bloodletting & Miraculous Cures and a Toronto emergency physician, has been selected to write a new biography of Tommy Douglas, the "father of Canadian medicare" and the ever.

Pretty good gig, eh?

The book will be published by Penguin Canada as a part of a new series of 18 books called . The series, which also includes a biography of Dr Norman Bethune by former Governor General Adrienne Clarkson and books on people from Louis Riel to Marshall McLuhan, is to be edited by Ms Clarkson's husband, the writer John Ralston Saul.

Dr Lam's inclusion in the series came as a surprise to some critics.

"Yes, there are the expected biographies of politicians such as Tommy Douglas (but by the unexpected Vincent Lam, winner of the 2006 Giller Prize for English-language fiction)," wrote The Globe and Mail's James Adams.

Besides Ms Clarkson and Mr Ralston Saul, the series features a number of other very well established writers like M G Vassanji, Margaret MacMillan and Douglas Coupland. The only nonfiction Dr Lam has to his name are some newspaper articles and a co-writer credit on a book called , and his fiction publishing is limited to his short story collection as well as a forthcoming novel called .

Toronto Star publishing reporter Vit Wagner called the Lam-Douglas choice "an intriguing matchup." , "The pairings sometimes seem odd, if never completely counterintuitive. Vincent Lam on Tommy Douglas? Well, Lam, besides being the Giller Prize-winning author of Bloodletting and Miraculous Cures, is a doctor; Douglas was the father of medicare."

If Dr Lam seemed an odd choice to some, he seemed well matched to the task to others. "Why not?" Toronto Star critic Dan Smith. "It’s the rich authorial voice and hopefully unexpected perspectives that will make these brief histories succeed; we won’t be looking for new facts or discoveries."

The Canadian blog Taylor & Company, however, didn't approve of the choice of Dr Lam... or of almost any of the other authors... or most of the subjects. Under the headline "" Chris Taylor criticized the number of Toronto and Ottawa writers, of whom Dr Lam is one, chosen to write biographies (13 of the 17 announced so far) and suggested his own list of biographical subjects -- zero of which overlapped with the Penguin list.

Lumping in Dr Lam -- whose Chinese parents immigrated to Canada from Vietnam -- with the "CanCulture elite" is questionable, but the real test will come when the Douglas biography is released, at an undetermined date in the next three years. Despite his Giller win, some critics have called him a "media darling" and at Bloodletting.


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, a longtime Halifax MP and former leader of the federal NDP, announced earlier this month that she .

Ms McDonough's exit will be a loss for Canadians in several respects. Without her, there will be zero female MPs in Nova Scotia, New Brunswick, PEI, and Newfoundland and Labrador. She has been a stalwart voice on behalf of women's issues in Canadian politics and greater female representation (though that idea hasn't caught on in Atlantic Canada yet) for more than three decades.

She has also long served as an important advocate for the continuing survival and strength of Canada's universal healthcare system.

Those two passions were intertwined in 1988, when a lawsuit against outspoken abortionist Dr Henry Morgentaler (read our Q&A with him ) went to the Supreme Court.

In December, I interviewed a number of prominent Canadian political figures about the 20th anniversary of the , which effectively cemented the full legalization of abortion throughout Canada. The comments, from Ms McDonough as well as Heather Mallick, Judy Rebick, Dr Carolyn Bennett, Margaret Somerville, and others, appeared in a special section on the decision's anniversary in the January 15 issue of the National Review of Medicine under the title "." Here is what Ms McDonough told me about her reaction to the 20th anniversary:

"I have to say it's hard to separate between the personal and the political. [Laughs] I threw myself into the women’s movement and electoral politics at the same time. When the decision came down, I had been in politics for 10 years, involved in the women's movement and past my childbearing years. So it didn't affect me in terms of my body, but it did affect my soul, my small-p political outlook.

"At the time -- and reflecting on it 20 years later I believe even more strongly now -- the impact of the decision did two things: it empowered women to be more forthright and assertive and more deliberative in making their own decisions in reproductive choice; it was like a milestone in that sense. And I honestly believe it forced some coming to grips with the truth in the healthcare community. The reality is there were a great many healthcare personnel -- doctors, nurses, workers -- who wanted to see the reproductive rights of women fully respected and asserted, but didn’t want themselves to perform abortions. In many ways the healthcare personnel are to be admired in their response, for them to be truthful about that. In the process it created the option which most people felt to be a preferable one, for there to be specialized reproductive health services not in hospitals but in community settings -- which is less bureaucratic, more personal. I think a lot of doctors felt they were able to be more truthful once the option of community-based clinics existed. Those who respected choice could say, ‘I don’t really want to do abortions as part of my practice, and I am glad a more supportive setting exists,’ and I don’t think a lot has changed in that sense.

"I remember going to visit my sons who were both away at university, at Queen's, in about 1995, only to discover they had both participated in a pro-choice rally, a march, and I thought, 'Wow, the world has changed a lot.' You might have expected that from daughters, but the fact that sons did it -- and didn’t find it exceptional enough to mention -- it was reassuring that the universe is unfolding the way it should. Mind you, they didn’t tell their mother what they were up to all the time." [Laughs]

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What exactly is going on in the Alberta Ministry of Health?

The news that four of the province's top public health physicians, including the acting provincial health officer, Karen Grimsrud, with the government because of a pay dispute, has sparked speculation across Alberta about the reasons for their sudden departure.

Several theories have been floated:

1. Doctors are greedy. This appears to be the government's explanation. Granted, Health Minister Ron Liepert didn't actually say that explicitly, but just take a look at :

"There is a limit as to what the government of Alberta can pay for certain positions. As much as we hate to lose them, this is just normal process where if you can find a better opportunity, you take it."

Dr Ameet Singh, the departing public health specialist on infectious diseases, however, that Mr Liepert's not quite telling what those of us outside the legislature would call "the truth." In fact, she , she has had no other job offers. "Maybe he's not aware of the fact. It's not all about money. It's a combination of things."

2. Budget troubles: the cabinet's recent meant that the government had no money left to pay its senior public health doctors. The timing of the two events -- the raise and the resignations -- is undeniably unfortunate, but does that mean they're connected? Nope, says the government. But the general public seems to like this theory. The Edmonton Journal's had a few examples of it:

"The health minister says the public doctors' contract demands were unrelated to pay hikes cabinet members recently gave themselves. Their contract money comes from the same trough as MLA salaries, and to get the best doctors we have to pay them top rates."

"Does Ron Liepert think before he opens his mouth? To suggest there is a limit to what the government of Alberta can pay for certain positions after giving himself a 30-per-cent-plus pay raise is ludicrous. Perhaps if Premier Stelmach and his people had limited their pay they could afford these key people."

And a letter to the editor of the Calgary Herald last Thursday expressed :

"Once again, the province's ruling oligarchy has abandoned all traces of foresight and rationalism. It is (almost) inconceivable that Ron Liepert expects the public to accept there is a limit to what the government can pay for certain positions, when only a few weeks have gone by since the Conservatives' own cash grab."

3. Policy dissent: the public health physician exodus can be attributed not to money but instead to recently announced reforms to the government's health governance policy. This theory, perhaps unsurprisingly, is the view espoused by the Alberta NDP. "[The news of the doctors' imminent departures] indicates a very strong reaction against the direction of the government, which clearly is toward private health care," leader Brian Mason . John Church, a professor of health policy at the University of Calgary, , "It points to the continuing lack of a good relationship between the politicians and the department of health." The government, of course, vehemently denies this.

4. Enough is enough: the public health department was getting shafted, and the doctors were getting frustrated. Dr Richard Long, the provincial medical consultant for tuberculosis, , "I do know that there were some concerns that the office was not adequately staffed and that the government needed to step up to the plate and support the office."

So, which of these theories is correct? At this point, it's difficult to tell, but all but one of them reflect poorly on the provincial government -- and that's the one the government is pushing and no one seems to buy. And even that theory -- blame the doctors -- doesn't make the government look very good.


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Alongside names like James Orbinski, Eric Hoskins and Samantha Nutt, Dr Paul Thistle is arguably the most chronically underappreciated of the chronically underappreciated group of Canadian physicians whose contributions to international humanitarianism have largely escaped the national media attention that would rival that of, say, or a whale that's been .

Dr Thistle (far right), who I , is the chief physician at Zimbabwe's Howard Hospital, a position he came to through his work with the Salvation Army. He's not just the chief physician; he's also the only permanent one at the moment at a hospital that serves a population of about 250,000 people. "It is difficult," he said when I asked how he was managing during Zimbabwe's recent troubles. "We try to keep our doors open and our shelves stocked when other healthcare institutions have shut down, victims of the political and economic crises." His work is as heroic as his obscurity in his native country has been unjustified.

But this month, two events have at last put Dr Thistle in the public eye.

Last week, the University of Windsor gave him an .

And the week before, the Royal College of Physicians and Surgeons of Canada announced that Dr Thistle has been selected as the first recipient of the , which the College describes as follows:

This award is named in honour of Dr. Lucille Teasdale and Dr. Piero Corti, a physician couple who devoted their professional careers to healing, teaching, and improving the condition of the population residing in the poverty stricken Gulu region of Uganda. For 35 years, the couple served in this region where there are frequent outbreaks of infectious diseases, and provided medical care throughout nearly 25 years of Ugandan civil war and unrest. Their medical and surgical skills saved thousands of lives; their teachings instilled hope for a better future in many; and their perseverance transformed a small missionary dispensary into the St. Mary’s-Lacor Hospital, which is now a modern teaching hospital and medical centre almost entirely staffed by Ugandan health care professionals.

The purpose of the Teasdale-Corti Humanitarian Award is to acknowledge and celebrate Canadian physicians who, while providing health care or emergency medical services, go beyond the accepted norms of routine practice, which may include exposure to personal risk. The recipient’s action will exemplify altruism and integrity, courage and perseverance in the alleviation of human suffering.

Dr Rachel Spitzer, a University of Toronto medical school graduate now working towards a Master's in Public Health at Harvard University, worked with Dr Thistle at Howard Hospital as a resident. She is one of the people who nominated him for the award. "Despite the fact that things are getting more difficult and the NGOs are departing, [Paul] seems more committed than ever, because the need is greater than ever," she told me last month. "Paul is an extraordinary individual. He is honestly and truly a good humanitarian."

In recognition of Dr Thistle's work, a number of Canadian businesses a donation of $2.3 million of medicine, supplies and equipment to be sent to Howard Hospital this month. The announcement was by Dr Thistle, Zimbabwean ambassador Florence Chideya and Liberal MP Dr Keith Martin.

Finally, the media have caught on. CBC News, which followed Dr Thistle's with great interest in 2005, spoke with Dr Thistle for an , published yesterday. In addition, another CBC News article published yesterday provides the of Dr Thistle that no mainstream media outlet had done before.

One of the most incredible things about Dr Thistle is his sense of humour, which he has managed to maintain admirably despite the trying conditions in which he works.

"At this moment in Howard's history," wrote Dr Thistle in last month's edition of his Zimbabwe Bulletin, published by the Salvation Army, "we see the byproducts of the past: the malnourished children, the hypertensive widow with stroke unable to afford the escalating costs of transport to hospital. People are hungry and tired. Everyday is Lent in Zimbabwe."

And, in spite of all he's seen, he still manages a smile. "Business at my liposuction clinic has been sagging."

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