American readers: Many of us here in Canada think that your leader, President Obama, is clear-eyed and wise and is trying to guide you to a crucial choice. Please heed him. Good luck and good health. This article looks at, and tries to clarify, centralization and decentralization, rural + regional + medical school delivery spectra, free enterprise versus socialism, & other currently controversial and ever-relevant health care topics. Caution: this is ‘merely’ one old Canadian doctor’s perspective on some internal aspects of universal medicare. Nevertheless please think on it.
CENTRALIZATION VERSUS DECENTRALIZATION OF HEALTH CARE
SPECIALISTS VS GENERALISTS, NURSES VS DOCTORS, SCIENCE VS ART
COMPASSION VS COMPETENCE, HUNCH VS EVIDENCE…
A FALSE DICHOTOMY?
The blind leading the blind by Bruegel. Where is your country? Your leader?
Our country, Canada, unlike the United States, is certainly not in the category of Bruegel’s medieval depiction of life-disabled. We have a fair to middling Medicare. It’s flawed, but still working. Our life expectancy is high. Our perinatal death rate low. Our people are getting taller and stronger (perhaps not always slimmer). But, some of our leaders are blind, if not stupid, and are on the verge of bogging us all down as in the picture above.
One factor to consider in looking at health care is this: Is there a trend to periodic or cyclical change in health care per se and its delivery? Yes. Over the years, there have been periodic swings in ideas about where to place medical services. Right now (2009), for instance, the Niagara Health System (NHS in Canada) is shrinking away from its more outlying areas in order to concentrate services centrally. Fifty years ago, on the other hand, before NHS was ever thought of, there was a strong movement to locate numbers of medical services outward, to wherever people lived. Before that, at the turn of the twentieth century, the American-generated Flexner Report focused upon upgrading the quality of medical education, and hence medical practice, all over North America – effecting a dramatic and seminal historical shift away from the horse and buggy doctor. So there are always changes afoot, sometimes rational, sometimes fashionable.
Each of these changes was accompanied by its own rationale, sometimes reaching an irrational level of propaganda. Certainly there was – and is – hype by whatever name. These movements or ideologies cannot be all right or all wrong, as their proponents and opponents would have us believe. So, where lies the truth?
It is noteworthy that, more or less coincidental to the above changes, the idea of universal health care, or medicine for the masses, began to be thought about and in some places applied. What has driven it is the inevitable advancement of human rights in general. Not economics. Not politics. Not medical science. Medicare for all is a branch of the Human Rights Movement. Consider it a special basic human right! The other three changes noted above – better doctors, local access, specialization centrally – have been driven by entirely different ideologies or motives.
SCIENCE & better doctors
A hundred years ago, to the Art of doctoring was added science. Science became the driving force in all of medicine. Flexner, a non-medical teacher and renowned scholar, essentially said, expose young MDs in training to the discoveries of Pasteur, Lister, etc., and the practises of such as Osler, and you will all have more competent doctors. It could only be hoped that compassion was not lost in the process.
Now, it being said that scientific medicine is preferable to quackery, we can take an honest look at the seemingly mutually exclusive delivery systems involved in decentralization and centralization and other seemingly mutually exclusive ways and means. First, however, it should be said that one particular type of doctor – the general practitioner or family doctor – never took part in either of those delivery-shifting movements. That species of doctor, however demeaned or lionized, whether doing house calls or not, has always been where the people are – not merely in small towns and the rural countryside, but also in the big cities and even at the universities – everywhere. I am not saying this to extol the virtues of the family GP. It’s to point out that the issue of centralization over decentralization has been the domain of the specialist and never the generalist. The specialization of medicine, and its interpretation and implementation by managers, has somehow played a major part in and determined the prevailing fashion of ‘sophisticated’ service delivery. I must also point out that the interpretation by managers and bureaucrats sometimes can be driven by other factors besides the science of medicine. Economics, power-grabbing, or even fraud, often are disguised by an impassioned public appeal to the ‘wise use’ of resources. Catch-phrases crop up: ‘best practise’ or ‘modern medical methodology’ or ‘centres of excellence’ or whatever appellation can best get across what is wanted to be gotten across by those who know how to spin things.
Two types of leadership: I’ll boil it down to another most important underlying factor, right here, in two sentences: 1) When doctors (instead of managers) run medicine, doctors and services tend to go where the people are at. Good! But the specialist doctors, being closet prima-donnas, always like to play the leading role. Even in the midst of complaining, they enjoy running big specialized hospitals at the very centre of things. They’d even take over the smaller peripheral hospitals if the country doctors would let them. (Now don’t get me wrong, I’m a specialist, a super-specialist, a former med school teacher – and I like specialists. But I’ve also always done general medical practice. So I think I understand how things stand with all the different brands of my fellow doctors.) Now I’ll get tough. 2) When managers run medicine, they want all the specialists in one spot, the family doctors be damned. For they often see non-specialists (in their lingo) as no better equipped than nurses and certainly not as good as paramedics. (In some cases they might be right.) The managers then claim that big centralized, specialized hospitals are best for all. Peripheral places are useless. So, total managed medicine is like the cart pulling the horse. You must be wondering, is there any rationality in any of this? Well, not unless you really go a step further and break it all down into a very simple question and that is: What works best?
Let’s proceed by breaking that crucial question down at three clear levels: what works in 1) outlying areas, 2) regional centres, and 3) schools of medicine (nursing, paramedical, lab support, etc.). We’ll look briefly at each, starting with the last.
The university centre: Medical schools have to have the departments you should never see elsewhere. That would include reproductive science, genetic research, anatomy, physiology, heart and lung transplants and the like. I also think that Schedule A (tertiary) Psychiatric Hospitals should be university hospitals. But, to get on with my point, as the med schools have student doctors to teach, they also must have a bit of everything else, the mundane clinical things, quite readily on tap. Granted! But they’ll never have rural medicine in a university town, so, if they want to produce any well-versed doctors of that sort, they must rotate them out to the boondocks for locum tenems on the hoof. As a case in point, when I taught at the University of Buffalo’s medical school, I sent/brought family practice residents across the border to work and learn in small-town (Fort Erie) and small-city (Welland) emergency departments. They taught us too! That’s all I’ll say about that, as it is just background to our main concerns, regional and outlying areas.
The wider region: An axiom of the foregoing (limits ascribed to academe), is that regions (like Niagara) shouldn’t be playing the game of ‘we’re as good as any medical school.’ They aren’t and they cant be. But they can be topflight (up to a point) clinically. Any goodly-sized region should have a centralized burn and trauma centre, a state of the art cancer treatment service, a child psychiatry centre of excellence, a … the list should be worked out by the specialists in consultation with family doctors and, believe it or not, by getting feedback from the ‘raw material’ of it all – patients, people at large, politicians (a bit), economists, and whoever else might have some kind of relevant stake in it. (But don’t be overwhelmed. When in the Soo-Algoma region, I was swamped with the personal, idiosyncratic suggestions of too many people altogether. This person said addiction came first, that person said, catch them young – children come first. Not being a Solomon, I decided to set up a community register that reflected what was really needed as opposed to what was merely wanted. What came highest were services for the indigenous peoples. Then I ran into evidence of denial and/or bigotry. “We do not have those problems here,” and the like. Then came arguments about whose responsibility is it? “Not ours – it belongs to the Federal government.” Eventually, rationally phrased statistics in concert with public wishes prevailed.) What I’m saying is, don’t be boondoggled, be properly informed. We need to be aware of the actual and the possible, what is ideal and what is economically feasible. Some medical-surgical services ought to be very well centralized in a fine regional hospital. And some things should not. Some services should be recognized as primary, all across the board. Those services ought to be spread outward and around.
Now for a brief diversion to make the next point, which is – getting things closer to patients: Back in the 1960s the community mental health movement epitomized decentralization. It was humane, emptied the hundred year old, monster, ‘snake-pit’ mental ‘asylums’ (with a boost from the new anti-psychotic medications), put psychiatric wards in just about every medium sized general hospital and – ultimately failed because money was not forthcoming to go a step further and provide true community care. Sad sick mental patients are seen lolling on every city’s sidewalks, as a result. But even this failed social experiment, hyped as modern science, was not entirely rational. Founded upon President Kennedy’s personal concern for people like his intellectually retarded sister (only somewhat like in actuality), it obviously had a deeper motive. It was a pet personal project. But as legislation was passed, it was laced with unproven hypotheses, all given wild political spin. So, a good thing unfinished, presumed modern, can simply become the fashion of the day or decade.
Outlying places: The ‘specialities’ that should not be centralized are primary, core-medical-skills that are translated into services that belong as close to every patient’s home as possible. They need to be in the medium sized city hospitals and some even in outlying rural hospitals. What are these core services? Emergency rooms, diagnostic labs and varying levels of imaging, small obstetrical units and miniature paediatric wards, low to medium level cardiac intensive care units, day surgery (not too specialized), some beds for the treatment of medical illnesses and near-home geriatric and psychiatric care, and a selection of specialized outpatient departments. As one gets further out into the periphery, these various core services can and should be manned by generalists, not specialists. Specialists should be on tap as consultants but not in primary charge of patients. The family doctor is a natural front line coordinator and doer and should be on top of what happens to patients. More specifically, emergency departments in medium sized cities need ER specialists, but those in small rural hospitals can be handled quite adequately by experienced and up to date GPs. If an outlying hospital could have nothing else, that one thing should be an ER. Finally, no emergency room can safely be more than ten to fifteen minutes away by ambulance from anyone in its catchment area, else time-critical life or death emergency patients will die in transit. This crass slogan applies: there will be – deaths – otherwise.
Obviously, I am touting the much neglected needs of outlying areas here. Why? If small town people are not catered to every bit as well as those in larger places the human rights aspect of universal health care is betrayed. But aside from that, it has been shown that decentralized medicine and hospital care, in small towns and small cities alike, is not only close to home and hence humane, but also more cost-effective than super-specialized and over-centralized Medicare.
Innovation: Everyone can reap the benefits of the most sophisticated of specialities – cheaply! By capitalizing upon local talent, which is indigenous all over – in rural areas, small towns, medium sized cities – millions of dollars can be saved. Front line people are capable. Innovation works! In child psychiatry (more generally too), I once had a choice of creating expensive central clinics with huge staffs or setting up highly responsive roving casualty teams that visited the schools, children’s aids, the courts, etc. By so doing, the real front line workers, public health nurses, teachers, very junior social workers, police juvenile officers, clerics, the list is long, were educated right on the spot and recruited to help upset children during crises, on the hoof. This was shown to work in Hamilton, Sault Ste. Marie, Haldimand-Norfolk, even Wawa. So, no one can ever tell me that the whole answer is mere bricks and money. It’s so easy, costly, and potentially harmful to ‘export’ patients to a far away ‘centre of excellence.’ Patient-centred, flexibility, outsight, innovation, mobility, and respect for indigenous front-line talent are the key words and ideas.
Dealing with managers, media, and their ploys: Dichotomous controversies can be the spice of life – at least the spice of media coverage. Remember, something repeated a thousand times becomes the ‘truth.’ Here are 18 common health care propositions of present day Goebbels-in-disguise. Test yourself:
Specialists should run big city hospitals; general practitioners must run small outlying hospitals. [T] [F]
Medicare must be either centralized or decentralized – it’s the big new hospital versus the small. [T] [F]
Don’t buck change; the big boys know what they’re doing; go with the flow. But be innovative. [T] [F]
Medicine is either an art (subjectively compassionate) or a science (evidence-based in facts). [T] [F]
Physicians know either a little bit about a lot (the GP) or a lot about a little (the specialist). [T] [F]
Family and general practitioners can be replaced with paramedics & nurse practitioners. [T] [F]
Politicians, administrators and doctors know best how Medicare should be delivered. [T] [F]
Money’s always the bottom line. You can throw it at anything. That solves all issues. [T] [F]
Medicare must conform to the law of supply and demand. If not, it will be rationed. [T] [F]
The people themselves, especially as patients, know best what doctors should do. [T] [F]
Modern medicine, by prolonging the lives of sick people, damages the gene pool. [T] [F]
Close any outlying ER !!! – more ambulances with paramedics can fill the gap. [T] [F]
One must clearly decide. It’s gotta be one thing or the other. [T] [F]
You’re either for life or against it (abortion, euthanasia) [T] [F]
In medicine it’s either free enterprise or socialism. [T] [F]
Seeing’s believing but feeling’s the truth. [T] [F]
The doctor always knows best. [T] [F]
An apple a day…
Hold on now! I’m not gonna be confined to any simple-minded, yes or no, answer. And I certainly will not be confused by multiple questions in one sentence. I have a brain in my head and must think on it. I’ll take time out to ponder the issues. There’s more than one way to skin a cat. Now that’s gotta be true. Maybe.
A single note to physicians: Too many Canadian doctors are altogether too polite and agreeable. Under that facade, they may actually feel ineffectual. So they come across as disinterested and apathetic about general health care controversies. They look to Big Brother in the medical society (CMA, OMA, etc.) to fix things for them. They may even figure that government will fix things for their patients. Not very likely! Not without strong medical input. Anyway, doctors tend to lay back and wait while Rome burns. But we doctors can do useful things locally in little ways. Here’s just one: We should, of course, be able to agree to disagree – in abstract philosophical discussions. But, if a lay-manager implies that you should politely do just that, agree to disagree agreeably, even though s/he is actively pressing ahead with some medically foolish act or a totally bureaucratic change, recognize it as a ploy and disagree vociferously. Here’s another piece of advice – to GPs: Don’t be squeezed out of work to become only a paper-pushing referral agent. Keep up your front line generic skills. Become THE expert on the family. Learn how to do some real counselling – individual, marital, family. Deliver babies. Above all, take ER call-duty. Do not let any insurer, manager – or specialist for that matter – reduce you. You are the basis of all Medicare. Put your foot down and dig in your heels.
Conclusions: Finally, to reiterate, it’s not centralization OR decentralization. It’s what and how much where. It is getting core services out to people where they live. It’s concentrating highly specialized resources at an accessible central point. It’s not starving or dismantling outlying services supposedly to put up central bricks. And it’s utilizing all doctors, including GPs, at the points in the delivery system where they’ll do most good. I might add that accountants, managers and government bureaucrats have a crucial role in health care, and that is helping with money matters and ensuring that medical services are delivered rationally. Not by whim or by idiosyncratic ideology. Certainly not as silly power ploys designed to build personal empires. All parties, especially politicians, big money private sources, and consumers too, must clearly recognize that medicine or health care delivery is a human service, not a manufacturer of material goods. In that respect the health field does not satisfy the usual commercial-business laws of simple supply and demand – need, or demand, is always outrunning supply. Why? New discoveries perpetually create ever-expanding demands. So costs, even streamlined, will always go up, and up … but fact (or hope?) of ordinary people helping people is always the same.