White Coat, Black Art·Dr. Goldman's Blog

The secret to improving health care

The best fixes for Canada's health-care system may come from a source that's almost never consulted. @NightshiftMD says the answer may surprise you.
The study's authors say that Canada needs to invest in primary care because countries that do so have better outcomes, lower costs and greater patient satisfaction. (Melanie Glanz/CBC)

Canadians are healthier than ever before. Still, there are big gaps in Canada's health-care system. An article just published in the Canadian Medical Association Journal lays out some suggested fixes. 

Irfan Dhalla and Joshua Tepper from Health Quality Ontario used data from the Organization for Economic Cooperation and Development and the Commonwealth Fund to compare Canada to other industrialized nations.

Overall, Canadians have good outcomes. Our five-year survival rates for cancer are as good if not better than other nations. Our unexpected death rates rank very well.

On the bad side, Canadians wait longer for non-emergency care. Twenty-five per cent of Canadians wait eight weeks to see a specialist, compared to just three per cent of people in Switzerland and the U.S. Fifty-three per cent of Canadians see their family doctor within a day or two of asking for an appointment. That compares to 72 per cent who get same or next day appointments in other countries.

Canadians don't suffer more cases of preventable harm from medical treatment. However, patients who get new hips or knees are nearly twice as likely to develop blood clots on the lungs; those who have abdominal surgery are 37 per cent more likely to have postoperative sepsis.

Addressing health care challenges

The authors came up with a list of things they say should help address these shortcomings. They say that the system should use scientific evidence to decide which treatments to cover. By that analysis, psychotherapy for patients with depression should be covered, and arthroscopic knee surgery should be dropped.

They said that Canada needs to invest in primary care because countries that do so have better outcomes, lower costs and greater patient satisfaction.

They say the system needs to become more transparent to identify what they referred to as "hot spots" for improvement. In that way, they can discover and investigate quickly if a particular hospital has a much higher mortality or complication rate for a particular illness or surgical procedure. 

They also called for electronic health records that work seamlessly with one another so that the system used by a family doctor can transfer records easily to the system used by any hospital.

There was one more recommendation that caught my eye. My esteemed colleagues said patients should be involved in making decisions about what services should be offered by a particular hospital, a region or across the entire system.

The authors of the article in CMAJ say involving patients increases the legitimacy of health-care decisions. (Radio-Canada)

These days, we expect patients and their families to make decisions about personal health. Suggesting fixes to problems in health care is something very different.

Patient engagement

The authors of the article in CMAJ say involving patients increases the legitimacy of health-care decisions. They gave examples where this has worked. For instance, a large family practice in Ontario asked patients how to improve their services and ended up learning about improvements that they hadn't thought of.

To increase and refine patient engagement, they also said the system should give patients easy and secure access to their electronic access health records and should make it easier for patients to compare hospitals on success and complication rates.

There are examples in which patient engagement has improved health care. 

At Kingston General Hospital (KGH), I saw posted signs indicating handwashing rates by health-care workers at the entrance to every clinical ward I visited. That's a suggestion that came directly from patients and families. Before putting up those signs, handwashing rates at KGH were among the lowest in Canada. As soon as the signs went up, so did handwashing rates.

Often, patients notice big gaps in health care.  For instance, as many as one in four ICU patients develops PTSD. The parents of children who spend time in the ICU are also at risk. So too are patients with cancer. Despite the high incidence, hospitals did not address the problem of PTSD until patients demanded it.

Antidepressant withdrawal symptoms is another example. A significant percentage of patients who stop taking antidepressants develop side effects like dizziness, headaches and memory loss when they taper off their medication too quickly. Lots of doctors prescribe antidepressants, but very few know how to deprescribe them effectively.  Patients were the driving force behind developing effective dose-tapering techniques.

I would argue that patients (not doctors) are the experts at tapering.

Personally, I think there's great potential for the system to benefit from the input of patients and their families. Some hospitals like KGH seem very receptive to the idea. There's no question that has taken up the mantra of patient engagement.

But is that a substantive change, or is it marketing?

There are many people who work in health care who are apt to ignore the suggestions of patients. That, in my opinion, is a mistake.

The article in CMAJ also called on the system to include input from physicians. 

Ignoring that would be a big mistake too.

About the Author

Dr. Brian Goldman is a veteran ER physician and an award-winning medical reporter. As host of CBC Radio’s White Coat, Black Art, he uses his proven knack for making sense of medical bafflegab to show listeners what really goes on at hospitals and clinics. He is the author of The Night Shift and The Power of Kindness: Why Empathy is Essential in Everyday Life.


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