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E Lalor, MB ChB, FRCPC, Barrie, Ontario.

Tue, 09/25/2018 - 13:21

Excellent article.
I am a gastroenterologist, previously at University of Alberta, but practicing in Ontario, since 8 years ago. In my (solo) practice, we spent a lot of extra energy "triaging", making it clear to the referring doctors that they will need to contact us if the predicted wait (provided in writing), seems inappropriate, or if the patient's condition changes. Despite all that, I then spend considerable time, and sometimes emotional energy, explaining and apologizing to the patient that they waited so long, or distressing internally (depending on the diagnosis) that the wait was inappropriate, sometimes based on the quality of the referral (my specialist bias). Obviously much of your blog referred to improving primary healthcare for the public, which is one of the main problems.

I would argue that there is a medical queue for more than "rare exceptions". The medical wait for gastroenterology consultation can be longer than 12 months if you suffer from irritable bowel syndrome, and possibly 12-18 months if you need an average risk screening colonoscopy. We are constantly managing the waiting lists, and responding to urgent cases, and cases that have become more urgent.

While agreeing entirely with your 6 suggestions for improving Canadian healthcare, I would add to the list:

1)It is no longer appropriate or practical for Canada to be one of the last remaining countries (I think along with North Korea) to offer a Universal healthcare system, without a second tier. I firmly believe that a carefully organized "private system" is required, and so long as physicians are legislated to remain, at least partially, within the public system, both systems would thrive, the public system would improve, and certain patients, (in a somewhat "un-Canadian manner"), would profit from their own accumulation of wealth or private insurance, just like they can now buy a better car or a better home.

2) “Someone” needs to start "rationing", (or start a serious discussion about rationing) - New Zealand started this decades ago, it was most difficult, and essentially political suicide for politicians to propose, but the Canadian public system just cannot pay for everything that the public (and the doctors) wants. Canada is partly handicapped by being so close to the United States. I think we are trying to provide American-type healthcare, or better in some cases, to all Canadians, extremely expensive, and completely impractical.

That same "person"/committee (Federal Govt?) would also start analyzing cost-effectiveness, as the main tool, and things like gastrointestinal endoscopy, along with e.g. primary cardiac and multidisciplinary care, urgent cardiac care, and validated cancer screening would be selected as preferred or even dominant strategies (i.e. colon cancer screening - my bias - I would be perfectly happy if average risk screening was fecal immunochemical testing, (coming to Ontario soon, several years after many other provinces)).

When you are finished with the department of medicine, please consider moving into politics. I think you have done an excellent job in writing this, and luckily Andre Picard has circulated/ re-tweeted.

In the meantime, this discussion about meaningful healthcare reform needs to be circulated and enhanced. I see an article in Globe and mail Sept 21st about “private healthcare” has raised some interest (and some opposition).

E Lalor, MB ChB, FRCPC, Barrie, Ontario.
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