Monthly Archives: January 2014

The patient’s history of medicine

The earliest recorded ideas about health in the Western tradition come from Mesopotamia where health was linked to the will of the various gods and spirits. A disease of a particular organ was linked to the emotional state of the god associated with that organ. A specific offering was made by the ashipu or priest/doctor to that god in order to appease him or her and thereby achieve a cure. The ashipu was the intermediary who could communicate with the god on behalf of the patient and no doubt took his share of the offering.

If this seems bizarre, we have only to remember the current widespread belief in the efficacy of prayer for the cure of disease, and that almost every hospital has a prayer room. When illness strikes without warning, some of us are not entirely free of such ancient beliefs, we still fear that we have somehow angered the gods or that we might find cure through divine intervention. My mother went to the Chassidic rabbi in our community for help with my dying father’s cancer. I’m sure that she was not the only one, as the rabbi had developed a reputation for achieving occasional miraculous cures.

The modern remnants of these ancient beliefs have been considered by medical science. There have been experimental attempts to show the efficacy of prayer. A particular set of experiments have purportedly demonstrated the efficacy of prayer on patients who don’t know that they are being prayed for, by subjects who don’t know the patients for whom they are praying (reference). The design of these experiments has been the subject of some debate, of course, and the experiments have surfaced as many questions about the efficacy of double blind randomized control trials as about the usefulness of prayer.

The Savvy PatientThe particular gods related to each organ brings to mind the current extent of specialization. Specialist doctors are increasingly associated with particular body parts – from retinas to knees – and are revered much like the ancient gods of particular organs. Patients are often warned not to anger the gods of the organs. A large section of The Savvy Patient, an advice book for patients, provides very explicit instructions about how to relate to specialist doctors so as not to make them angry. Many patients tell us stories about experiences they have with doctors who become quite angry and dismissive if they ask too many questions, or want to describe their situation in more detail, or even ask to bring their relative into the examining room with them. The fear of annoying a doctor is quite real among some patients, which I think speaks both to the authority of the doctor and often the passivity of the patient. Historically these roles appear to go right back to ancient times.

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Third class patients cost Ontario as much as $28.4 billion

In my last blog entry, I tried to describe the three classes of patients in the current healthcare system by referring to the Alberta’s Health Services Preferential Access Inquiry. The third class users were:

  • Rural populations;
  • Individuals without family doctors, particularly individuals with complex medical issues;
  • Individuals with addictions and/or mental health issues;
  • The poor;
  • The elderly;
  • Individuals whose first language is not English;
  • Those with hearing or vision loss or mobility issues; and
  • First Nations communities

The Inquiry acknowledged that these groups were given inferior access to the system, but that looking into this was not part of their mandate. (The list may not be complete, but I will add to it if anyone thinks that there are other groups who have inferior access.)

Inferior access to health care has serious consequences. In fact access to health care is taken to be one of the more critical social determinants of health. If people cannot see a family doctor, then they can more often than not gain access to health care through the emergency department. The groups listed above have poorer health than the rest of us; lower life expectancy, higher unemployment, and increased levels of institutionalization.

This week the Health Council of Canada released a report that looks at how the different provinces fare using measures developed by the Commonwealth Foundation in the US. Provinces are compared to each other, and Canada as a whole is compared to ten other developed countries including Australia, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. The report gives us numbers about access as well as the health status of Canadians. According to the report, Canadians who have access to primary care doctors have their serious health problems managed well, but we rank last in our ability to get same day access to those doctors; second last in getting an answer to a question we ask them; third last in finding after hours care outside an emergency department.

In terms of our health status, 57% 0f Canadians have at least one chronic disease (the third highest among the eleven countries surveyed) and 31% have two or more. Arthritis, asthma and other lung diseases, cancer, mental health problems such as depression or anxiety, diabetes, heart disease, high blood pressure and high cholesterol levels are the chronic diseases they consider. We are among the highest users of drugs – 36% of us take two or more prescription drugs a day.

This information is best put together with the financial situation in Ontario: the top 5% of healthcare users consumed 58% of the healthcare $48.9 billion budget. By my calculation, these high users consume $28.4 billion. Let me repeat that – 28.4 BILLION DOLLARS! And the high users are almost entirely the third class patients we have described above. If ordinary Canadians have a high incidence of chronic conditions and also have some trouble getting same day visits and quick responses from their doctors, it is so much worse for the population with poorer access.

So here is something to think about. Ontario is spending a considerable amount of money. It seems pretty clear that if we better served third class patients before they are hospitalized, we might be able to avert at least a portion of that $28.4 billion.

Three classes of patients in Canada

Two years ago, a Commission of Inquiry in Alberta was called to explore improper preferential treatment in the healthcare system. It was a result of a public outcry after members of the Calgary Flames hockey team and their families were vaccinated for the H1N1 virus ahead of the general public during a declared pandemic. Other allegations of preferential treatment were made as well. The commission was formed with the mandate to consider, “whether improper preferential access to publicly funded health services [was] occurring; and if there [was] evidence of improper preferential access to publicly funded health services occurring, [it was to] make recommendations to prevent improper access in the future.”  Volume 1: Inquiry Report of the Health Services Preferential Access Inquiry was published in August 2013.

Alberta Health Minister Fred Horne in an interview with CBC regarding the inquiry’s findings.

The vaccination of the Calgary Flames team was investigated by the College of Physicians and Surgeons and Albert Health Services before the inquiry. The college found that the doctor in charge of the clinic that vaccinated the hockey players and their families, decision was “an error in judgement, not professional misconduct. As a result, the Investigation Chairman has directed that this complaint be closed. The public reaction to this incident, as well as the complaint, has served as very useful feedback to [the doctor involved] regarding the ethics of seeking preferred services for an elite group of individuals in a publicly funded health care system.”  On the other hand, Alberta Health Services fired the administrators involved in setting up this special clinic. The Commission of Inquiry found that this was indeed improper preferential access and a clear rule should be put in place to avoid such incidents because they undermine the public’s confidence in a publicly funded system.
The inquiry looked at several other cases where there might be a question of preferential access.  It found that where a physician deemed a case to be especially urgent and the patient was allowed to jump the queue once that diagnosis was made, then this could not be considered a case of improper preferential access. Even if the patient had special access to the doctor because of personal or professional relationships, once the urgency of the case was established, then there could be adequate medical justification for jumping the queue. The inquiry recognized that there was no way to stop the practice of “courtesy calls” where doctors see patients outside regular hours as a courtesy to their colleagues. As a result it looks like there is really no way of eliminating some level of preferential treatment of first class patients. But the inquiry concluded these patients should not be allowed to jump the queue without clear medical need.  It also found that this small group did not significantly affect the care of the rest of us.

The question of third class patients was not investigated by the inquiry. The commissioner declared that the inquiry was limited to looking at whether there were people who were “getting access that is superior to the norm.” It did not look at cases where people were getting access that is markedly inferior to the norm. However it did note that the groups listed below were receiving inferior access:

  • Rural populations;
  • Individuals without family doctors, particularly individuals with complex medical issues;
  • Individuals with addictions and/or mental health issues;
  • The poor;
  • The elderly;
  • Individuals whose first language is not English;
  • Those with hearing or vision loss or mobility issues; and
  • First Nations communities

These are the third class patients. So it looks like even today in Alberta, and probably across Canada, we have the same three classes of patients in our publicly funded system.  What do you think we should do about it? Are there others who should be added to the list of third class patients?

Three classes of patients

This year’s blogs will explore the history of medicine from the patient perspective.  In The Modern Hospital there were three distinct and well defined classes of patients.

Third class patients were placed in the large free wards. In these wards patients did not pay, and were considered to be charity cases. They were seen on teaching rounds and their medical care was part of the obligation of physicians to teach and care for all who could not afford it. Ignaz Semmelweis, who I referenced in a previous blog, was mainly concerned with this class of patients.

Second class patients were placed in small private wards. The costs associated with their hospital stays were typically paid for by their employers directly or through insurance.

First class patients were placed in larger private rooms. The Modern Hospital notes that a modular small ward could also function as a large private room (see the image in my blog about the modern ward). These spaces were reserved for wealthy people who would often get private nursing care to supplement what was provided by the hospital. Additionally, first class patients typically received private visits from prominent doctors who could charge what the market would bear.

At the height of his power, William Osler would typically charge about $300 in today’s money for such a visit. According to his biography (William Osler: A Life in Medicine; Michael Bliss, University of Toronto Press. 1999.) his hourly rate was roughly $600. Osler recorded his work and believed that between 15 – 20% of his time was without remuneration, which would indicate that Osler saw first class and third class patients.

Despite the stated view on visiting that I noted in my last blog on the patient in the modern hospital, there were three different sets of rules for the three classes of patients in the children’s department, for example:

Visiting time in the Children’s Department shall be as follows

  • Large (free) wards: 2:00 – 4:00 pm Wednesday and Sunday
  • Small (private) wards: 1:00 – 8:00 pm daily
  • Private rooms: without limitations aside from the order of attending physicians (page 340, The Modern Hospital)

A question worth pursuing is how much do these distinctions continue today? And if so, how do they manifest themselves?  I will explore this further in my next blog.

The patient in the modern hospital

This blog series has been leading up to the role of patients in the modern hospital. And the role is pretty clear. When reading books of the time, we see that patients hardly play a role in healthcare, except to bring his or her body along for treatment.

The medical superintendent, the matron, and all the other doctors and nurses made the decisions. The times were rather hierarchical and the doctor would decide most things and rarely consult patients. When patients entered the modern scientific hospital, they basically gave themselves over to its care.

Under the section ‘Hospital Visitors’ in The Modern Hospital, the author declares his position very clearly:

We may begin with the flat argument that it would be best for all sick people if all visiting could be prohibited and it is a recognizable situation in nearly every hospital that has visiting days that the temperatures are higher at night on the visiting days than at other times, all else being equal, and this is due to the excitement caused by visitors, not alone one’s own visitors but those who come to see other people…

In considering the visiting question, therefore, we have two or three fundamental ideas in the foreground; one of them is that we ought to restrict visiting as much as possible and we ought in any event to limit visits to the one patient whom visitors come to see. And visits should be as short as possible and whenever it can be done each patient should be restricted to one or two or at least a minimum number of visitors.

This is based on a seemingly scientific fact that the excitement of visitors causes the patient’s temperature to rise, hence it is for the patient’s own good that visitors are restricted. However, on reading further, one begins to think that the inclusion of visitors disrupts the orderliness of the hospital. It is best to allow as few as possible outsiders into its inner sanctum. Care for the patients is best done by those who are trained to provide it professionally, scientifically. The human body is the object of medical intervention and is best treated in isolation from all other influences that might disturb it further.

Photo from 'Yes Minister'These views are no longer current, but they do form a kind of baseline for change, as slow as it may be. In 1981 an episode of the British comedy Yes Minister comments on the issue by bringing the Minister of Health to present an award of excellence to St. Edwards – a hospital that is entirely without patients: “no patients” might improve quality even more than “no visitors”. The staff will be able to perform their duties without the distraction of real sick people. Perhaps this hospital with all its busy doctors and nurses cares for human bodies without feelings of illness, worries about their present condition or future state, and certainly without visitors who might disrupt the orderliness of the institution.

One of the questions for our time is how much of that old culture remains? And where does it pop up? Do you ever feel that you are intruding on the order of the hospital? That medical staff would be able to do their jobs more easily without your input? Or that their job is to fix your body or that of your family member and it would be better if you would simply let them get on with it? If so, you have found a remnant of The Modern Hospital of 1914. From the stories that come to us, some of it is still there, and we are hard at work to make it disappear.