Monday, February 21, 2000  National Post

Ontario doctors talk back

Dr. Sharla Lichtman

I am writing in response to a letter by Duncan Sinclair published in the Financial Post on Jan. 27 (Letters, Health Planner Talks Back).

Duncan Sinclair is the chairman of the Health Services Restructuring Commission. The HSRC is recommending rapid restructuring of primary care. This is the very same chairman and commission that recommended rapid restructuring of our hospitals. As a result of hospital restructuring, doctors and patients are now experiencing the worst crisis ever seen in health care. Hospital beds were closed at a time when a growing, ageing population required additional beds, and when there were insufficient facilities to accommodate chronic patients occupying acute care beds. Hospital restructuring was done at a time when there were inadequate home care services in place to handle the very sick patients who were either refused admission to hospital or discharged from the hospital when they were still very ill.

Duncan Sinclair states that family doctors have welcomed his plan for primary care restructuring. This is very far from the truth. Grassroots family doctors were not consulted by the HSRC. Family doctors who work on the front line have a very clear picture of how our system is ailing, what changes are necessary and what proposals are likely to sink us into an even deeper crisis. No one is better positioned than the family doctor to appreciate the psychological, physical and social impact of an illness on our patients, as well as to understand the repercussions of a crumbling system on every aspect of our health care.

Proposals put forth by the HSRC do not address our current problems. Furthermore, they introduce concepts that will remove freedom of choice from physicians and patients and serve to erode the very special relationship between family doctors and their patients.

The HSRC wants all family doctors to be forced into group practices. Family physicians will then be responsible to the group and the government bureaucrats administering the group, not to their individual patients. It will ultimately turn into a form of managed care, where quality care will be sacrificed.

The HSRC wants physicians' offices to be opened 24 hours a day, seven days a week, suggesting this will ease the current emergency room crisis. This is an attempt to remove the responsibility for that crisis from the government and place it on the shoulders of family physicians. The emergency room crisis exists because the government has closed hospitals and reduced the number of hospital beds available for very sick patients. These patients remain trapped on emergency room stretchers. In addition, there are insufficient nurses to care for patients because many have left our province due to government cutbacks.

Family doctors agree it is important for patients to have access to after-hours care. This could be accomplished by expanding upon after-hours clinics run by family physicians servicing the needs of their community. In fact, many of these clinics already do exist. Most citizens of Ontario do not have difficulty accessing after-hours care in their community.

The HSRC itself reports that 92% of the population has a family physician with whom they have a long-term relationship. How much greater than 92% could we ever hope to achieve? The concept of rostering -- assigning patients to group practices -- actually removes freedom of choice and mobility from patients. Once rostering has been introduced, the government will have paved the way to restricted access to specialists and hospital care. Specific specialists and hospitals will be associated with particular family physicians. Currently, family physicians, in consultation with their patients, can choose the specialist or hospital they believe best suited to a patient's needs and personality. The HSRC strategy may remove the right of patients to choose who will deliver their babies and who will perform surgery on them.

Finally, Duncan Sinclair wants physicians paid on a capitation system. This has already failed with other countries. Physicians will become, in effect, like salaried government employees. This is not an incentive to provide quality care for patients. Currently, family physicians work an average of 60 hours per week, working through lunch and sacrificing their family time to service patients because the demand is there and their patients need them. Why would we want to give doctors a disincentive to see patients when there is a physician shortage across the province? Yes, as Duncan Sinclair states, doctors are "overworked, underpaid and suffer punishing hours of office and hospital work." Unfortunately, the HSRC strategy will not eliminate these problems, and will serve to weaken the very special and unique relationship between family doctors and their patients.

Sharla Lichtman, MD, CCFP, president, The Coalition of Family Physicians of Ontario.

Sinclair's plan won't cure system's ills

Dr. Suzanne R. Strasberg

I read with amusement Dr. Duncan Sinclair's response to Dr. Stephen Cord's three cases of patients demanding medical tests of questionable need (User Fees Are Not the Way to Cut Health-Care Costs, Feb. 14).

First, it has only recently come to my attention that Dr. Sinclair is not a doctor of medicine but a doctor of veterinary medicine. While I am sure this is information that has been available to us all, without question the vast majority of people assumed that the "Dr." responsible for restructuring our hospital system and now proposing to drastically alter our system of primary care actually attended medical school and has had an opportunity to treat patients himself. If he had, I'm sure he would be more sympathetic to Dr. Cord's plight.

We have all been in situations where we have ordered tests because of patient expectations. A good example of this is checking cholesterol yearly at an annual physical in a person over the age of 35 with no co-morbid diseases. Questionable testing occurs in situations where the patient is not financially accountable. Primary care reform will do nothing to address this situation, as the Canada Health Act already forbids it. The only person penalized when a patient goes outside his primary provider is the doctor.

Second, there have been no studies to my knowledge that demonstrate that patients receive superior care in a capitation model -- where doctors are paid per patient, regardless of how much or how little they treat the patient -- when compared with a fee-for-service model. While fee-for-service may provide incentive for some physicians to provide extra services to generate income, very few do this. As Dr. Sinclair stated, "I am confident [in] the professional integrity of the overwhelming majority of Ontario's physicians." Capitation, however, certainly provides incentive to do as little work as possible, and while I also believe, like Dr. Sinclair, that in most cases patients would get their services, the undertone of his comments are that physicians should continue to work even once their annual payment cap is met, or otherwise we have broken one of the "fundamental tenets" of our profession. Does Dr. Sinclair forget that we are also small business owners with salaries and overhead costs to pay?

Finally, Dr. Sinclair and others have suggested that primary care reform will alleviate emergency room congestion because doctors will be available to their patients 24 hours a day, seven days a week. This is false. The recent emergency room crisis was of Dr. Sinclair's making. It occurred because hospital beds and entire hospitals were closed on his recommendations without thorough planning or forethought. Yes, there are patients who go to emergency rooms with trivial ailments that could be treated in their family doctor's offices. However, these patients did not create the emergency room crisis. It was created by critically ill patients occupying beds in the emergency department for days because Dr. Sinclair's restructuring committee had closed beds that should have been available to them.

I agree that there are problems in the current system. However, the system provides excellent care to the great majority of Ontario patients, and most patients are extremely satisfied with the care they currently receive from their family doctor. Extended-hours coverage and other problems in our current system can be solved without exchanging the current system for one of questionable value.

Why does Dr. Sinclair want to forge ahead so quickly again? I would have expected that he would have learned his lesson from the current hospital fiasco.

Suzanne R. Strasberg, MD, CCFP, Downsview, Ont.