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Differing diagnoses on Health Care

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, MD.

"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 each other."

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 wisdom.

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 year."

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 here.

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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