Minnesota Medicine published a piece in their current issue entitled “Comparing Health Care Systems” (April 2010) that begged a response so guest blogger, Dr. Henry Kahn, kindly agreed to share insights he gained from extensive experience with the Canadian healthcare system:
Articles such as this appear in academic journals all the time. There is always a comparison of financing and health care outcomes among western countries that suggests the American health care system is wasteful and inferior. However, there is a significant disconnect between what these articles report and what is observed by people who live in these countries. The frustrations and disappointments experienced by health care providers and patients in Canada, for example, are never captured by these academic presentations.
I am a third-generation Canadian who trained as a urologist in New York City between 1960 and 1964. I practiced in Winnipeg for 38 years, was an associate professor at the University of Manitoba, head of urology at a major teaching hospital for 23 years, and head of surgery at a 132-bed community hospital for 30 years. After that, I was an urologist with the Mayo Health System in Owatonna, Minnesota, for more than seven years. I’m now retired.
The following is a short list of problems I encountered in Winnipeg:
- At any given time, elderly clients who were waiting for nursing home placement occupied about 30 percent of the beds in urban hospitals, thus making those beds unavailable for acute care
- In any given year, all elective services would be suspended for an aggregate of about three months because of holidays and summer closure. Hospitals close for at least six weeks during the summer and for one week around holidays such as Christmas, New Year’s, Easter, Thanksgiving, Queen Victoria’s birthday, and Memorial Day.
- In the operating theaters, there could be no overtime because personnel who worked more than 15 minutes overtime had to be paid for at least four hours at two-and-half-times the normal rates. Thus, procedures that could result in overtime were routinely rescheduled.
- Procedures that require implants such as cataract surgery and hip and knee replacement were strictly rationed.
- Entire sections of the hospital were routinely closed when the facility’s annual budget was exceeded.
- Medical staff were not replaced when they retired.
- Outdated equipment was not replaced. For years, cancer patients were treated with radiotherapy machines that were not equipped with computers to accurately direct the beam.
- There was a shortage of primary care physicians in Winnipeg, so finding a family doctor could take two years. More than 50 percent of the doctors in rural Manitoba are recruited from Africa and Asia, according to the Manitoba College of Physicians and Surgeons. This is the result of a policy adopted by the federal government in 1975, which reduced medical school enrollment across Canada by 30 percent. The decision was based on the recommendation of an eminent health care economist at the University of British Columbia who thought that health care costs would be reduced if there were fewer providers.
- There was a dire shortage of diagnostic equipment such as imaging machines.
In Canada, there is a waiting list for everything but care for dire emergencies. For an imaging test, the waiting period is three to four months. The waiting list for the surgical treatment of urgent cancer cases is at least three months. Unfortunately, these waiting periods are not concurrent. It usually takes six months or more to get from the point of presentation to treatment. Not surprising, there are plenty of horror stories.
In 1995, during a severe influenza epidemic, there were 70 patients on gurneys in the corridor of a 132-bed hospital. At the time, 60 beds were closed because of budget concerns, and all elective procedures and admissions were ceased for more than two weeks. As chief of surgery, I had a patient with a perforated duodenal ulcer who had languished for more than 10 hours on a gurney in the corridor without diagnosis or treatment. I gave a public television interview, which was broadcast live on the evening news; the very next day the 60 beds were opened. Many of my cancer patients had their surgeries cancelled because their surgery might require staff to work overtime. These patients underwent extensive preparation for major surgery, only to be sent back to the ward.
My family, too, has experienced the long waits and inefficiencies. In 2002, my sister fell off a bicycle and sustained a comminuted wrist fracture. She waited on a gurney in a hospital corridor for three days before she could have an open reduction and fixation. In 2005, my sister, who lived in a rural area, was diagnosed with an acute lymphoma. She waited for three weeks to see an oncologist. By then, her cancer was too advanced and could not be treated. In 2008, my brother developed an ugly lesion in his mouth. He was slated for a biopsy as soon as possible. It took nearly five months for him to have the biopsy. A poorly differentiated cancer was diagnosed, but it was too late for anything other than palliative radiotherapy. A cousin felt something snap in his shoulder while playing tennis. It took more than six months to schedule a magnetic resonance study. It took another month for him to see a shoulder specialist. By that time, the tendon had deteriorated and surgery was not possible. He will never play tennis again. A relative with bowel symptoms is currently scheduled for a colonoscopy. The date has been set four months from now.
The Canadian news media regularly report the most dramatic cases. In 2003, the Winnipeg Free Press reported the story of a 58-year-old woman who died after waiting two years for heart surgery. Recently, media across Canada have followed the story of Brian Sinclair, whose primary care doctor sent him to the emergency department of the largest hospital in Winnipeg with an obstructed indwelling catheter. He was there for 34 hours and never examined. He had been dead for hours before he was noticed. Last month, CBC News reported on the sharp increase in the number of cancellations of heart surgeries and cardiac-related tests in Manitoba over the last three years, including 43 cancellations in December 2009 alone.
The problem in Canada is that health care institutions are given a fixed amount of money at the beginning of the year. The cost of all services then drains it. Instead of viewing the patient as a source of income, the institution sees the patient as an expense. There is no incentive to offer more expeditious care. A responsible and successful hospital administrator has to find ways to downsize, and this can only be done by rationing and curtailing care.
The sixty-four-thousand-dollar question I have is this: Why is it that the academics who deride the free enterprise system in the United States fail to capture the misery that socialized medicine brings with it?
Henry P. Krahn, M.D.
Retired urologist
Owatonna
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