September 9, 1992

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Nelson GP Dr. Gregory Siren, who has been practicing for three years, predicts a dis- couraging future for other young doctors. Here, he examines a patient's ankle.

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Day

‘ don't think the public knows there's not enough money to run the system for a full 12 months.’

— DR. VAN VLIET Castlegar BCMA Rep

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Nelson BCMA representative Dr. Don Burgess

‘| have a long career ahead of me and I'm sad to say it looks quite discouraging.’

— DR. GREGORY SIREN Nelson GP

ill with cancer, anxious

family members and friends gathered at his bedside Now imagine that, instead of increasing medication and treat- ment, the life support systems are suddenly unplugged, the patient left to fight for life with his own dwindling resources of strength.

Absurd? Perhaps. Yet the patient in this case is the entire B.C. medicare system, the spreading cancer, the mushroom- ing costs of modern medical tech- nology and abuse of the system. Yet government officials seem only able to stand at the bedside and watch while health care costs spiral out of control, far beyond the capacity of its life support system, the taxes and premiums that keep it alive. In desperation, doctors are blamed for their inability to save the patient while being told to do so with less resources.

At least that’s the doctor's eye view. In the wake of the furor that erupted earlier this year over the NDP government's proposed fee capping legislation, B.C. doctors feel they have been made scape- goats for rising health care costs. “Rather than attacking physi- cians’ income,” says Nelson GP Dr. Gregory Siren, “there are other issues regarding health care costs that could have been addressed.” Nelson BCMA repre- sentative Dr. Don Burgess adds that it’s not the job of doctors to manage government finances. “Our job is patient care—the con- cem shouldn't be, ‘can we allow a patient in or will it exceed the budget’.” He says the govern- ment has failed to address the increasing costs of medical tech- nology, the greying of the popula- tion, and the influx of people moving to B.C. One of his Patients, diagnosed with brain cancer, had to wait three months for a Catscan, adversely affecting his prognosis.

The procedure is incredibly expensive and largely subsidized by ‘the Medical Services Plan (MSP), whose budget only allows it to run three days per week in this region, based on area popula- tion estimates. Patients needing hip replacement surgery currently face a 15-month waiting period “We've worked very hard over the years with government to keep it under control, but our

[es a patient, seriously

The doctor's eye view

ofa

failing system

Story and photos by Arthur Joyce

increases haven't been propor- tional to the costs,” he says Castlegar BCMA rep Dr. Van Vliet adds that the BCMA esti- mates there is about a $60 million annual shortfall in current gov- ernment budgeting for medicare, set at about $1.2 billion. “I don't think the public knows there's not enough money to run the system for a full 12 months.”

Dr. Burgess suggests that par- ticularly in the case of the termi- nally ill, sobering decisions must be made. “We have to look at whether vast amounts of drugs and treatment, increases the qual- ity of life if you're merely post- poning the patient's death with two years of misery,” he says.

Yet doctors are caught in an ethical ‘Catch 22°, wherein potential lawsuits may be launched on the premise that everything possible was not done to keep a patient alive. Aad while it has been suggested that the high proportion of births deliv- ered by caesarean section is due to the higher fee doctors receive, this may simply be a symptom of the fear of litigation if a natural childbirth goes wrong.

And what about those fantas- tic incomes doctors earn? Dr Siren acknowledges that public sympathy will rarely rest with a profession traditionally labelled as the top-earning group in the country. However, statistics often state gross income without allowing for 40 per cent in over- head expenses. Not to mention the debt in time and money incurred before a doctor begins his or her practice.

Dr. Siren spent five years in medical school, three years undergraduate and two years postgraduate training, and has been in practice just three years. “I’ve had ten years of no income,” says Dr. Siren, “I drive a ten-year-old car, have an aver- age house, and a student loan that will take me ten years to pay off.” After practicing medicine for 30 years, Dr. Burgess earns an annu- al income of $80,000, but could hardly be said to put in a normal work week. “I start at 7 in the morning, work until 6, plus another 12 hours for emergency ward shifts, so about 60 hours a week,” he says. “If you project what we're earning per hour, it’s not out of line with what other professionals earn.”

Doctors point out that this is without the benefits other profes- sionals take for granted, such as holiday pay and pension, and that they earn one fourth the income of American doctors. And unfor- tunately, the very nature of the fee-per-visit system can be an incentive for physicians to sacri- fice quality of time with patients to quantity. “It’s a personal choice I’ve made to spend 15 minutes with each patient, where others might only spend 6 and double their income,” says Dr. Siren. “I'm not paid to spend time with people.”

Particularly galling to physi- cians is the way in which govern- ment policy changes to the MSP have been implemented, bypass- ing the usual channels of negotia- tion. What set the fuse burning was Bill 13, which dealt with physician renumeration and pro- posed fce capping as a cust-cut- ting measure. Bill 14 subsequently disposed of govern- ment-funded pensions for doc- tors, and the current Bill 71 encompasses the previous two but with further changes to health care regulation. “They brought it to the table and four weeks later it was law,” says Dr. Siren, “replac- ing through legislation a previ- ously negotiated plan. It’s alarming when your rights are legislated away.”

He claims this follows a long history of doctors losing ground to government control of health care, resulting in a declining morale in B.C.’s medical profes- sion. “Fee capping was just a

screen used to enlist public sympathy,” he says.

To counter this, the BCMA’s campaign of office closures and health care ‘rationing’ has as its intent the compelling of the gov- ernment back to the bargaining table, and the gaining of greater public awareness and support. Dr. Van Vliet says with the coming of fall we will likely see further office closures and many physi- cians opting out of MSP, particu- larly specialists. “If we were a union, we'd have shut down the Province months ago. Under the new bill, if the money runs out you work for two months free, and you can be kicked out of the system for virtually any reason,” he says.

Solutions, anyone? Someone? One option is direct billing to the

patient with reimbursement from MSP, but even physicians are divided as to the benefits of this solution. There is consensus, however, on the need to reduce abuse by patients of the current system. The government could address this problem by excluding from coverage excess office vis- its, non-essential procedures, and lifestyle-related maladies such as high cholesterol or recreation- induced injuries.

A public information campaign regarding the costs of medical procedures would also likely be useful. “The public is ignorant, through no fault of their own, of what things cost,” says Dr. Siren, “but it’s the government's respon- sibility, not doctors’, to educate them.” Dr. Van Vliet doubts the government wants to handle such a political hot potato. “Telling people they have to be more care- ful with the system doesn't get you votes,” he says.

Another suggestion that has been made is a salaried system of pay and benefits similar to those in some European countries. “I'd love to be salaried and have regu- lated hours of work, but I don’t think government could afford it,” says Dr. Siren, “and you could end up with less productivity.”

Could this be the end of medi- care as we know it in B.C.? While it is true that the Canadian system of universal medicare has been touted as the best in the world, it is buckling under the weight of ever-mounting costs. Indeed, many Americans look with envy upon our system, which prevents people from becoming impoverished by unex- pected injury or illness.

“There's no question it’s a bet- ter system than the U.S. has,” says Dr. Siren, “but is it better than the Dutch, the German, or other systems?” Dr. Burgess believes it is simply a case of under-funding, and that the public would likely be willing to pay a little more so as not to lose a good thing

Yet, to those who are new in the medical profession, prospects appear bleak. “I have a long career ahead of me and I'm sad to say it looks quite discouraging,” says Dr. Siren. “I think it could be the end of medicare, if enough opt out,” says Dr. Van Vliet, “but the truth is, doctors are poor at turning people away.”