Differing diagnoses on Health
By Stephen Dale
The Globe and Mail, July 9, 1983
Midway through 1978, a young post-graduate doctor in training drifted
dourly through the antiseptic glare of Toronto Western Hospital
like some James Dean in intern's fatigues: weighed down with discontent
at the medical mores he was supposed to be learning to love; alienated,
frustrated and silently opposed to the powers that were overseeing
his passage into doctorhood. Dr. Fred Freedman, now a physician
in private practice; had certain notions as an intern that "the
way the medical system was being run was wrong but out of discretion
and fear of the establishment he kept those ideas to himself.
One fateful afternoon, after a morning of crossed swords with the
hospital bureaucracy, the dam burst, and Freedman confessed his
"progressive" political soul to the intern who happened
to be standing next to him, outside the hospital's radiology lab.
The other's response, surprisingly, was one of recognition, and
following on that was a revelation that thundered home with all
the emotional velocity of a thousand final scenes from Marcus Welby,
"We were both feeling acute frustration with the system,"
recalls Freedman, whose youthful good looks would make him a star
candidate for General Hospital. "In effect, we turn to each
other for comfort and my God, we find it and we're both stunned.
The feeling was 'Where have you been?' We almost put our arms around
They had lunch together the following day, at which time the pair
poured over the plight of isolated "progressives" within
the gold-plated world of medicine, and exchanged visions of what
health care in Canada should be like. Shortly after that emotional
union, the Medical Reform Group of Ontario (MRG) was born.
Today the MRG boasts a membership of more than 200 - about half
doctors and halt medical students, based mainly in Toronto and Hamilton
- a puny platoon when compared with the Ontario Medical Association's
army of 15,800 doctors but still, a growing voice from the fringes
where before there was only silent compliance. The renegade medics
of the MRG insist they aren't really radicals; that many of their
key tenets for reform were the same ones stressed in Federal Health
Minister Monique Begin's first (though aborted) draft of the impending
Canada Health Act. Still, up against what some characterize as the
extreme ideology and enormous influence of Canada's official medical
associations, these kamikaze medicos appear to be dive-bombing conventional
The ferocity of their disagreement can be seen in the MRG's founding
statement, in which it delivers a stinging rebuke to the Ontario
Medical Association. Calling the association "a powerful force
for retarding progressive development in the health care system,"
they chide it for being "too conservative and overly self-interested."
Between David and Goliath there comes an entire philosophy of medicine.
With health care in Canada plunged deep in crisis (basically because
there isn't enough money to feed the system), the feeling is that
something's got to give - and the medical lobby is determined that
it won't be doctors' salaries or status. Enter the progressive medics
with their "small is beautiful" heresies. They are against
large salaries, against lots of high -tech medicine, and for more
accessible "primary" health care delivered through community
facilities. They also feel it's high time to "democratize"
the health system, to scrap the "archaic hierarchy" of
doctordom and to invite other health care workers and involved citizen
groups into the limelight of medical policy-making.
Dr. Michael Rachlis, a salaried doctor at the South Riverdale Community
Health Centre and the MRG's resident expert on medicare, attributes
the current health care conundrum directly to the preponderance
of fancy surgery and the new and expensive high-tech medicine that
many doctors consider " sexy". Rachlis says the return
on those things is not high enough; that a doctors' collective might
and individual expertise would, in general, be better directed toward
environmental, occupational and preventive health care.
"What we're seeing now," says Rachlis, a balding softspoken
man with a passion for statistics and a penchant for subtle sarcasm,
"is that we're spending all this money on health care, and
it's not really doing anything for health, that it's making no real
difference in terms of morbidity and mortality rates. The major
determinants of health in our society are related to housing, nutrition,
occupation and that type of thing. Those ideas were radical 10 years
ago, but now they get front-page coverage in The Wall Street
Journal. It's becoming clear that preventive medicine is what
gives you the big bang or your buck."
What does not make economic sense, says Rachlis, is paying an increasing
portion of health budgets to doctors, at the expense of other health
care workers. "If the trends continue," says Rachlis,
"with doctors getting more and more of the pie, and less and
less available for other health workers and for innovations such
as community medicine, we're going to be facing a tremendous squeeze,
where your grandmother and my grandmother will be able to get coronary
artery by-pass surgery, but she's not going to be able to get a
$5-an-hour home care aid to keep her in her home."
Rachlis also takes a shot at medical education, not because it represents
poor economy, but because, claims Rachlis, it is socializing doctors
inappropriately for a profession demanding of mercy and imagination.
The MRG believes that modern medical training fosters an aristocratic
attitude on behalf of doctors, isolating them from the concerns
of average people, and confining them to the inbred hierarchical
world of fellow physicians.
"Doctors undergo what is without a doubt the harshest of any
professional training," says Rachlis. "And if you look
at the hospital environment, where most doctors are still trained,
it is the closest thing in our society to the military. You have
several different classes of workers, and within each of those six
or so professional groups, you have at least four or five different
levels. For doctors there are about ten links in the chain of command
from the chief of medicine to clinical clerks who are just med students
. . . Everyone has uniforms, and the nurses have different stripes
to denote their rank. They don't salute each other; but there are
certain informal salutes.
"The training itself is not unlike marine boot camp: there's
extremely long hours, you step out of line and you're subject to
degradation; and it's not surprising when many doctors are through
they tend to function with this extremely rigid frame of mind. It
breaks you down; One of, the over-all effects of this is that it
removes people from the real world so that they can no longer relate
to day to day problems that people face. The other, I think, is
that it really removes analytic capabilities. Many doctors have
lost the capacity to think."
Dr. Debby Copes, another physician in private practice and a member
of the MRG, steering committee, feels the trials of "getting
doctored" are reflected in current physicians' economic demands.
"I really think it leads to the belief that once you get out
you deserve whatever you can get - like, 'I've suffered, I've done
my time, all those hours on call, why shouldn't I be paid well for
it now?' "
Which brings us back to the subject of money, a threat to many relationships
at the best of times, and something which hasn't won medical reformers
much respect among their peers.
"Generally we disagree with the finan-cial preoccupation of
the OMA and are on the side of the public," says Freedman,
"which I think feels that doctors are generally making a fair
piece of the cake, and that it's time to say 'wait a minute, how
much of our health care budget is going towards paying doctors'
bills' . . . We get a lot of resentment from the medical pro-fession
because they tend to see themselves as under attack, so when we
stand up on the public's side, they take it personally. There seems
to be some degree of discord' and anger."
Those types of responses - anger, and perhaps disdain - are what
one might expect would greet such uninhibited critics o an almost
sacrosanct profession. Yet the official reaction has been almost
conciliatory. The provincial ministry of health, which has jurisdiction
over administration of health services has invited the MRG to its
"Health Care in the 80s and Beyond" conferences (the MRG
has accepted). One ministry official indicated the group's ideas
are given "due consideration along with those of the OMA."
The OMA's response has been cool.
Eugene O'Keefe, director of communications for the OMA, refers to
the leftist doctors and their barbs more with amusement than anger.
O'Keefe contends that the OMA promotes a balanced health care system
- and has paid ample-attention tc preventive medicine. "How
far does it go?" O'Keefe asks, "Do you have a nutritionist
on every block? . . . A lot of pre ventive medicine is also education,
but there the compliance factor enters in. What if people refuse
to act on the education - do you force them to change their lifestyles?"
As for the MRG itself, O'Keefe notes the high proportion of its
membership in medical school, and sug gests that "because they
are young they like to take on specific causes, as one always does
in university . . . A lot of people want to change the world over
night, which I suspect is the case with many members of the Medical
Reform Group. "
How does a tiny band of idealists go about trying to change the
world? At first it started small: beginning as a mostly for covert
and low-key groupoperating mostly to provide self-support for "progressive"
doctors who were "coming out."
"I joined in December of '78 when it was still in the stage
of meeting in Fred's house," says Copes. "At that first
meeting what I found was some old friends whom I hadn't seen since
medical school, whose politics I really hadn't been aware of. I
also found a sense of relief that the people I was mainly surrounded
by, the doctors I worked with every day, were not the only kind
of doctors there were: that there were doctors who shared my views."
Shortly after that the MRG went public, struck a constitution and
began to participate in various issues. During the hospital workers'
strike of 1979, the group voiced its support for the CUPE strikers
and organized against using interns for so-called "scab"
labor. Later, several MRG members founded a store-front occupational
health clinic in Hamilton (which has since folded due to financing
problems). The group has also broadened its influence considerably
by hooking up with the Ontario Health Coalition, an amalgamation
of 17 like-minded special interest groups including labor unions,
seniors, church and native peoples' groups, the Registered Nurses
Association of Ontario and the Social Planning Council of Metro
Toronto. The leadership of those organizations is MRG, most mainstream
doctors have said to collectively represent three million shown
themselves to be more concerned Ontarians.
Yet both the MRG and the OHC have round their major battleground,
predictably, to be the troubled territory surrounding extra-billing
and opting-out by doctors. Coincidentally, the MRG went public around
the same time the current epidemic of opt-outs began to sweep the
country, and it's this phenomenon which has bestowed upon the group
much of its momentum and membership.
Like the official medical associations, the reformist doctors are
awaiting the release of Begin's new Canada Health Act (and trying
to influence its content in advance), as that document should provide
the definitive word on extra-billing. The minister has hinted that
the new act will lower the boom on doctors who have opted out of
medicare, in order to bill patients directly and at their own rates.
In the late '70s the level of opted-out doctors increased from a
traditional level of 8 to 10 per cent, prompting many groups like
MRG to fear the rise of a two-tiered medicare system, where only
those who could afford it would receive superior health care. The
medical associations, however, feeling that doctors had dropped
in status during the years of the anti-inflation board, began to
lobby in favor of a doctor's right to opt out and set his own prices.
For a few doctors, like occupational health physician Dr. Brian
Gibson, to be a part of a doctor's organization that campaigns against
medicare is an unbearable contradiction. Gibson, on staff at St.
Michael's Hospital, department of environmental and occupational
health, and a teacher at the University of Toronto's faculty of
medicine, quit the OMA in 1982 "when they raised membership
fees by $100 to build up the war chest," having simultaneously
been a member of the MRG for two years before that. Gibson chose
medicine as a second career in 1970 (with an MA in near Eastern
Studies, he had previously been a Biblical scholar) because "I
wanted to be involved in something of direct use to people."
Gibson is opposed to the OMA's stance on opting out because he feels
medical care is too important and too central a service to peddle
privately. "If medicine is something offered on the market
just like any other commodity," says Gibson, "then of
course doctors should be paid for it. They have to take on the responsibility
of providing it for a reasonable price to everyone."
Other MRG members remain part of the OMA, though they oppose extra-billing.
Rachlis, for one, is tied to the official body through his insurance
policy, although "it galls me tremendously that they're spending
so much of my money fighting medicare. It's estimated that the medical
associations in Canada will spend $2-million fighting medicare this
Just where you stand on extra billing is pretty much representative
of how you feel about doctors. To members of the MRG, most mainstream
doctors have shown themselves to be more concerned about their pocketbooks
than the public they serve. They cite studies of the experience
in Saskatchewan, where hospital user fees were implemented between
1968 and 1971, to indicate that use of medical service by low-income
people is drastically curtailed by additional fees. They also look
with horror to Australia and New Zealand, where comprehensive medicare
systems have been virtually dismantled, and wonder if it will happen
From professional experience, Freedman complains "I can't
send my patients to get things done without paying unless I plead
with the specialist, saying 'This person is really poor.' I shouldn't
have to do that."
Yet O'Keefe at the OMA finds the MRG's stance a cynical one. He
defends opting out as "a safety valve" against doctor
strikes, and maintains that most doctors have the discretion not
to charge poor patients. "A doctor may be individual recalcitrant,"
says O'Keefe, "but the majority will recognize on a referral
that 'This person is on welfare,' or over 65, or a single mother,
and they will respond to that…I think doctors in the Medical
Reform Group could find agreeable doctors, but they want to box
the doctor in and have all of their patients get free care because
that's their philosophical bent. There comes a time when a physician
might say 'That's not going to work. That's not the way I practice.'
He's going to reserve the right to make judgement calls, just as
he does in medicine."
The orthodox view is that a doctor deserves that power; that, with
his special knowledge and power over life and death, the modern
medicine man should have licence to make those critical "judgement
calls." On the other hand, the Medical Reform Group represents
another viewpoint - committed to "de-mystifying" the profession,
to stripping the doctor of his near-priestly status and making him
instead a public servant. And that, for many doctors, is the worst
demotion of all.
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