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!

Antoine de Saint – Exupery: Wind, Sand and Stars

Explorers and adventurers have always fascinated me and there are endless books in this genre. Robert Scott’s tragic diary, the tale of the USS Jeanette and Captain James Cook’s travels are all personal favourites. What drives us to seek adventure or take enormous risks, when we have but one life to live?

Saint-Exupéry’s Wind, Sand and Stars, a memoir of his time as an aviator in the early days of flight, tries to answer this and many other questions. What do we derive meaning from? What is a life well-lived? The writing itself provides his answer, as he approaches the world with a child-like sense of awe, the pages dripping with majestic imagery and metaphor, often reflecting a sense of pure joy.  If he must choose specificity (dates or other particulars) or beauty in recounting his experiences, he opts for beauty and wonder.  Where Orewell’s Homage to Catalonia, a memoir from the same era (both men were in Spain during the civil war), reads like a log of his time, mixed with withering analysis, Wind, Sand and Stars is a piece of art where light on a plane’s wing radiates “in the form of a bouquet of pink flowers.” The titles reflect this difference best.

Though not an explorer, aviation itself was in its exploratory stages.  Saint-Exupéry flies by sight and map, with only rudimentary controls, in small planes that feel the full brunt of nature’s effects.  Navigating by the stars, his course dictated by the wind, he crosses the Pyrenees and the Andes, sails through typhoons, crashes in the Sahara and nearly runs out of fuel over the ocean.  When thought lost for dead in the Sahara he notes that he has “gambled and lost” but has no regrets. He states clearly that “it is not danger I love. I know what I love. It is life.”

Life isn’t shuffling papers in a government office or earning a certain arbitrary amount of money. Man is not “cattle to be fattened for market.” Man’s fulfillment is not to be found in logic, it is to be found in what culture, activity or scale of values brings self-fulfillment or awakens an inner spirit. For Saint-Exupéry the plane was a means towards experience. One does not die for air mail, the same as most men in a war do not die for whatever banner they happen to fight for. Far from escapism, shirking off daily drudgery for something more is the embrace of reality.  Finding beauty, in music or art, is reality.  Love is experiencing this with another person. This is the only way to realize one’s full potential, to test one’s self, to experience freedom.

Consumerism and technology are a constant backdrop to this book.  Saint-Exupéry initially is supportive of new technology, noting that over time it is eventually accepted. The plane, he notes, doesn’t divorce man from nature or feeling, it puts man in touch with nature. At the time this was quite true as he flew in a tiny plane, feeling the cold, rain, his vision obscured by clouds, his destination governed by wind that flew in his face. But what would he think of a modern airplane, on auto-pilot for 90% of the flight, the pilot not feeling the wind or viewing the stars, but instead a series of knobs and monitors? Of a world where any place on Earth could be viewed with the click of a button? Where, like his prisoner digging a hole for punishment, work is neither purposeful nor enriching? Where a car drives itself? This is what I wondered as I finished the book.

It seems I may have received my answer as I then read that Saint-Exupéry went missing in his plane in 1944, just as airplane navigation became heavily dependent on reading instruments, which he was not enamoured with. When a French fisherman pulled his nets in 2004 he found a bracelet with Saint-Exupéry’s name inscribed and his plane was found shortly after. It had no bullet holes and appears to have flown directly in to the sea, with suicide strongly suspected.

I suspect Saint-Exupéry would hate much of the modern world, as it eliminates wonder and joy. For being a world divorced from reality.  One wonders if he hasn’t got to the reasons for why our modern world, despite its benefits, is so full of depression, anxiety and isolation? Where men in droves seek nothing as they see nothing offered in return. Perhaps the technology is no longer a means, as his plane was, but an end itself.

A truly brilliant book and I’d highly recommend reading this back to back with Orewell’s Homage to Catalonia. Was Orewell truly fighting mainly to rid Spain of fascism? In favour of socialism? As he states he joined mainly as it was the thing to do in Spain and his best justification at the end of the war for choosing his side and being shot in the neck is a weak plea that no war is without a difference depending on the victor. I suspect Saint-Exupéry understood better than he what brought Orewell to arms.