Jeffrey Simpson: Chronic Condition

This entry is a bit late coming. Why? I hated this book!  You tend to not pick up a book when you aren’t enjoying it. I didn’t quit, I gutted out all 376 torturous pages.

Chronic Condition is a look at Canada’s health care system, written by Jeffrey Simpson. Full disclosure, I’ve never liked Simpson. I’ve always thought he is a Liberal party stooge that toes the media line and never says anything interesting. The main problem with this book is that Simpson is a political writer, not a policy wonk.  I never got the impression he understood the Canadian healthcare system or even how the bureaucracy works. A political affairs writer is essentially TMZ for something more important than Snooki. It covers people involved in public policy, but it doesn’t get into the ins and outs of government programs and policies.  As a result the book was scattershot, highly repetitive and dedicated 100 pages to a political history of Canadian health care, when it could have been 10.

I never gave too much thought to the ins and outs of our health system in my twenties, but over the past two years I’ve been chronically ill. My partner is also an MD and we talk a lot about her work. The system works well in some ways (making sure people at immediate risk of dying don’t die mainly), but the more I learn the more I realize that it is an inefficient and incoherent mess. And nobody seems to mind this. Like all  massive bureaucracies “that’s just the way it is” and good luck changing it. I don’t think that’s good enough when it accounts for 40% of our provincial taxes!

I was hoping this book would give me some real insights, but I knew there’d be little insight when, speaking on the matter of finding efficiencies in the system, Simpson just says “that never works.” True it is inordinately hard to change the way a large, complex and entrenched system functions, but the book should be about giving it a crack. The other glaring omission is that Simpson barely speaks at all about what technology can do to make health care cheaper, or to better serve patients.

The book confirms that if you have cancer or are in a horrible car accident, you’ll be treated first and receive excellent care. It is everything else where we fail: wait times for specialists; treating chronic conditions; access to primary care; mental health services; and overall navigability.

In 2017 our medical system still runs on paper, phones and fax machines. Doctors communicate and refer among each other based, in large part, on who they happen to know. This is beyond inefficient, it is wasteful.

The system also serves mainly the practitioner and not the patient. Horribly ill and have to move 500 kms away? No, the Doctor will not talk to you over the phone for even 5 seconds. You must travel 1000 kms.

For the patient there are no options, no evident triaging based on need, no knowledge of what records are sent where. My family Doctor is part of a family health team that operated an after hours walk-in for its patients. Great, it’ll keep people out of the emergency room. At some point the after hours clinic stopped operating, but nobody ever told me. They don’t email patients. They don’t have a website. They have no incentive to inform me of how the system works, so why would they bother?

In my own case I waited so long to see specialists, that I ended up in the hospital for a couple of weeks.  This is probably, without exaggeration, 1000 times more expensive to the state than the ten 15 minute appointments that never happened.

At my wife’s clinic, probably 10% of appointments are not kept. Perhaps an automated auto-dialer or e-mail reminder might help lower this number? Nope. No time to call people.  That’s 10% of the time for someone being paid, on average, $250,000. Might as well burn $25,000 for each Doctor at the clinic (there are about 6 so that’s $150,000, almost enough to hire a new Doctor or a couple of nurses).

There should be some obvious priorities to fix:

  • Mandatory electronic health records that are connected to all physicians and pharmacies and which the patient can access. We do this for our taxes, why not health care?
  • Referrals to specialists that are structured, not based on who a Doctor happens to know. If a patient is willing to travel 1000 kms if it saves three months wait, let them have the option. It frees up space and gets people healthy.
  • Electronic referral, based on your geographic location and your health problem, to the correct practitioner (hospital, family Dr, nurse practitioner, walk in clinic etc.).
    • Let’s say I have a cut that needs stitches. Where should I go? I know that the hospital will deal with this, albeit after about an 8 hour wait. This is by far the most expensive place to go for the system. Is there another option? How do I even go about figuring this out? I don’t know. I doubt others do either, so they go to the hospital.
      • It is assumed patients understand how the system works. They don’t. How would they?
    • Do we need a yearly check up? My wife gets people coming in for these appointments, but they are apparently unnecessary.  How would the patient know this?

I agree with Simpson on this: some private medicine is a good idea; pharmaceutical prices should be negotiated by the federal government (we pay the 2nd highest prices for drugs in the world); there should be nominal fees for access ($15); and funding should follow patients and performance.

All and all a dull read that only touches the surface of what’s wrong and likely what’s possible. It could have been fascinating and there is still an amazing book out there for the right author!