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Dominican Republic, Canadian Dental Relief International, and Hopes for the Future

Posted on 13 December 2015 by Matthew R. Kreher

People who visit the Dominican Republic think of resorts, snorkelling and beautiful beaches. They think of friendly, smiling people and shops for tourists to buy souvenirs.  When the plane touches down on the runway and you step onto the tarmac, you are greeted by a wave of warmth.  Palm trees wave hello in the light breeze. I have a different memory.  We were carting loads of dental supplies with us from Canada. I was travelling with the Canadian Dental Relief International, a group of dentists who decided to start giving back to the global community in the form of free dental care.

The first evening we set up temporary dental units and chairs, organized tools and supplies, and met the resident health care worker who had been providing rudimentary dental care thus far.  Over the course of only two weeks, her education had advanced in the areas of accurate anaesthetic delivery, optimal extractions methods and basic oral hygiene instructions.

We would arrive at the clinic day after day to lines of people coming from kilometers away. The people would wait at the clinic doors all day for toothache and infection relief. It was an intense and productive period of time where hundreds of patients were treated and a local health-care worker was trained.  All this was in the backdrop of beautiful, Caribbean sunsets and an armed guard to protect our sleeping quarters.  It was a country of poignant contrasts.  In hindsight, the people of the town were living in luxury compared to the depths of poverty I was to come across later on during the trip…

I remember the ride along a bumpy dirt road.  Dust created a veil in front of the surrounding landscape.  There were wide, rolling plains covered with tall green shoots.  The curious plants looked like a cross between corn stalks and bamboo.  These were sugar cane fields.  I liked it because it was exotic and because the crop stood so tall.  I imagined running through the stalks and getting lost in the maze.  There was a woody yet sweet smell in the air that was enjoyable save for the occasional intermingling of the car exhaust fumes.  The dirt road came to an end at the Batey.  This was a small village where the sugar cane workers lived.  Many of the workers were migrants from Haiti.  The men in the village spoke about their long days harvesting sugar cane.  They were friendly people but tired as well.  There were no doctors to provide care for them if they became sick. Canada, with dirt floors.  That was it.  That was the house built for a family of six.  The roof was low, too low for an adult to stand beneath without bowing their necks. There were some branches strung together outside to form a clothes line. So it went as we passed from abode to abode.  A ramshackle camp strung together with whatever buildings materials had been scavenged from wherever they had been scavenged.  There was a concrete cylinder in the center of town that housed the water supply for everyone at the Batey.  None of the shacks had running water or toilets.  They were just rooms.  Beside the water tank and in the center of town stood the single well-constructed building, which was a church.  I was struck by a sense of irony, but who was I to judge.  Whatever gets you through the day…or the life as it were…

After a tour we came to our purpose at the Batey. At the school, we presented posters and acted out skits for the children explaining the detriments of pop and candy on the teeth. I remember the kids laughing and playing games with one another. I couldn’t help but thinking that they were innocent to the truths of their poverty.  Perhaps innocence negated their poverty, at least until the point that their hunger pains began.

Looking out upon a vast field of sugar cane one was struck by the thought:  If we paid a dollar more per bag of sugar cane to help these people, would we do it?  Would the money get to them? Would their lives improve? The small act of adding a tablespoon of sugar to my tea was a silent acceptance of the servitude of men in foreign lands.  So the story goes, from the clothes we buy to the foods we eat, we are confronted with an Everest of serfdom.

I left the Batey, and the Dominican Republic with the same poignant contrast she loved to impart.  Mixed with the melancholy and overwhelming sense of powerlessness, my empathy and awareness for the difficulties of the world grew.  Balance what we take with what we give back.  You don’t have to look hard to find people in need.  As health professionals we have struggled to the top of a mountain for the privilege of a skillset that can help the world, it is our obligation to try where and when we can.

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World AIDS Day

Posted on 01 December 2015 by Zara Zalnieriunas

On this World AIDS Day we celebrate progress that has been made and we push to meet new goals to end the AIDS epidemic by 2030. This year the UN reached their target of treating 15 million people with HIV by 2015. In their new Fast-Track Strategy, they aim to have 90% of HIV infected individuals knowing their HIV status, 90% of those people to be receiving treatment and 90% of people being treated to have viral load suppression to the level where they are no longer infectious (the 90-90-90 goal) by 2020 and a similar 95-95-95 goal by 2030. Along with this, they are aiming to have new infections in adults down to 200 000 by 2030 and having zero discrimination is a goal throughout.
These are ambitious goals, but we have already seen proof of the amazing progress that can be made in this fight against the AIDS epidemic when world organizations come together to meet a target. We must continue with increased effort or risk back tracking as Michel Sidibé, Executive Director of UNAIDS, has stated, “We have bent the trajectory of the epidemic. Now we have five years to break it for good or risk the epidemic rebounding out of control.”
Here is Michel Sidibe’s 2015 World AIDS Day Message:
http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2015/
november/20151119_WAD2015
References:
http://www.unaids.org/sites/default/files/media_asset/JC2686_WAD2014report_en.pdf
For more information on the Fast-Track Strategy including materials to share on social media to show your support for the initiative: http://www.unaids.org/wad2015/

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“Pharmacare is the unfinished business of Canadian Medicare”

Posted on 23 November 2015 by Jessica Bryce

“Pharmacare is the unfinished business of Canadian Medicare” says a new report by Pharmacare 2020, an organization comprised of a number of prominent physicians, health policy workers, and researchers.

How did we get here? Why are prescription drugs not covered by Canadian medicare? Why don’t we need to show our health card when we go to the pharmacy? To answer these questions, we must delve into the history of Canada’s health care system.

Since the early days of medicare, many have argued that medications are a necessary part of a comprehensive coverage system. In 1945, the Federal government made the first proposal to the provinces regarding a national medical insurance system that, notably, suggested inclusion of drug coverage. In 1964, the Royal Commission on Health Services (informally known as the Hall report), recommended that the federal government assist the provinces in establishing a comprehensive, universal program for ensuring medical services (which was based on Saskatchewan’s system that was already implemented). This influential report also recommended that the plan include coverage for prescription drugs. Drug coverage was discussed at the federal level, but “was shelved because the government did not perceive sufficient public demand to make it a political win” (http://irpp.org/research-studies/study-no50/). Thus, it was not included in the 1966 Medical Care Act, a precursor of the 1984 Canada Health Act. Without federal direction, each province formed its own public drug coverage insurance plan for specific sub-populations. Most of these programs target seniors, low income families, and individuals with disabilities.

The idea of universal pharmaceutical coverage was not formally revisited at the federal level until 1997, when former Prime Minister Jean Chretien chaired the ‘National Forum on Health’. The forum identified two key problems with drug benefit plans:

  1. Having multiple bodies purchase drugs (i.e. private insurance companies, hospitals, provincial drug plans) reduced the purchasing power that could be had by a larger collective organization
  2. Seniors were under-insured for many necessary medications

Yet again, it was recommended that drugs should be included “because pharmaceuticals are medically necessary and public financing is the only reasonable way to promote universal access and to control costs.” (National Forum on Health 1997). In 2002, the Romanow commission recommended starting with federally-initiated catastrophic drug coverage. Then, incremental reforms could ultimately lead to complete drug coverage for all Canadians. This report lead to the formation of the National Pharmaceuticals Strategy in 2004. Unfortunately, funding decreased and progress was hindered due a change in the federal government in 2006.

Although not government sanctioned, a number of reports since 2002 have recommended a Universal Pharmacare Coverage program. However, a quick glance at the authors of these reports demonstrates considerable overlap. Although well written and researched, there are a limited number of groups and individuals researching potential pharmacare reforms in Canada, and even less ambassadors for it at the provincial and federal government level. However, as pointed out in the recent Pharmacare 2020 report ‘The Future of Drug Coverage in Canada’: “a July 2015 poll by the Angus Reid Institute found that 91% of Canadians support the concept of having “Pharmacare” to provide universal access to necessary medicines; 88% believe that medicines should be part of Medicare; 80% believe that a single-payer system would be more efficient; and 89% believe Pharmacare should be a joint effort involving provinces and the federal government.” Public demand for pharmacare reform is there, the research supports it, and yet there are no government initiatives and virtually no incentive for the government to do so. What should be done?

….. stay tuned for more!

 

References:

  1. Are Income-Based Public Drug Benefit Programs Fit for an Aging Population? http://irpp.org/research-studies/study-no50/
  2. Pharmacare 2020: The Future of Drug Coverage in Canada http://www.pharmacare2020.ca/
  3. 2014 Lobby Day Delegate Backgrounder https://drive.google.com/file/d/0B9cM-RadOUW2RzR5YW01UHNuZUk/view?usp=sharing

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What’s Stand Up for Health?

Posted on 01 November 2015 by Amanda Sauve

What’s Stand Up for Health & Why is it in our curriculum?

Health Canada recognizes 14 determinants that influence the health of Canadians including income, education, employment status, race, and gender identity, to name a few. As a student body we are familiar with social determinants of health, but often find learning their relevance in the classroom to be didactic and to put it bluntly, boring. A practical way to help students learn about these important issues is “Stand Up for Health,” an immersive simulation that gives participants a better understanding and appreciation of the social determinants of health. During the simulation participants are placed in the role of low income Canadians and must interact, make choices, and solve challenges within their given set of social circumstances. This provides students with exposure to some of the tough decisions made everyday by Canadians, and offers an opportunity for us to see through their perspective. The objective is to help us better develop the skills to empathize with patients, to identify healthcare limitations, and start conversations on how we can advocate for improved healthcare for all Canadians.

Stand Up for Health has recently gained recognition in medical education. It has been played at Ontario Medical Students’ Weekend (OMSW) 2014 & 2015 and the 2015 Canadian Federation of Medical Students (CFMS) Annual General Meeting in Windsor. Most recently, it has been integrated into undergraduate medical curricula at both Western and the University of Toronto. We’re hoping to permanently implement the simulation in our curriculum (for the 2020’s and beyond!)

If you (2018s or 2019s) would like more information or are interested in becoming a game facilitator (officially termed “change agent”), please contact Amanda Sauvé (asauve2018@meds.uwo.ca)

 

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Indigenous Health in Medical Education

Posted on 22 October 2015 by Maddy Arkle

As a Métis medical student, Indigenous health is a topic close to my heart. Indigenous populations of Canada (which includes First Nations, Inuit, and Métis peoples) have unique health barriers and concerns largely based on historical, geographical and social factors. In order to address the specific health needs of Indigenous peoples, many medical schools have begun recruiting Indigenous students and incorporated Indigenous health into medical school curriculum.

I was part of a fantastic group of students from medical schools across Canada that authored a CFMS policy paper titled “Indigenous Peoples and Health in Canadian Medical Education” (link posted below).

The motivation behind this paper was a desire to encourage and assist Indigenous students in pursuing medical school. We also saw a need to address the exposure of Indigenous health topics to medical students and faculty with a focus on cultural safety. There are many difficulties and barriers faced when addressing Indigenous health. Every medical school has responded to these issues differently. This paper provides a national standard and clear direction for the future of Indigenous health in medical education.

Here is a summarized version of the paper’s recommendations:

  1. Increase Indigenous medical student recruitment (in a culturally safe way)
  2. Develop admissions policies that are equitable for Indigenous students
  3. Include mandatory, culturally safe Indigenous health curricula during pre-clerkship
  4. Implement experiential learning* modules into pre-clerkship
  5. Involve Indigenous health in clinical electives
  6. Support Indigenous health-focused extracurricular activities
  7. Prioritize employment of Indigenous physician leaders, Elders, and support staff within medical
    faculties.
  8. Ensure Indigenous cultural safety competency in all educators and support staff.
  9. Increase accountability to local Indigenous communities

*Experiential learning involves learning through experience. Here it involves acknowledging the difference and value of Indigenous perspectives, knowledge and cultural practices.

While many of these recommendations seem obvious, they have not all been addressed by all Canadian medical schools. The CFMS officially adopted this policy paper at their Annual General Meeting (AGM) in Windsor in September, so now the real work will begin! This is a small but mighty step toward advancing and improving medical education surrounding Indigenous populations. Read the full policy paper here: http://www.cfms.org/attachments/article/1370/Indigenous_Health_in_MedEd_AGM2015.pdfhttp://
www.cfms.org/attachments/article/1370/Indigenous_Health_in_MedEd_AGM2015.pdf

Finally, a very special thank you to Ryan Giroux (CFMS National Officer of Indigenous Health), Amanda Sauvé (Local Officer of Indigenous Health-Western), and the other team members Max, Reed, Danielle, and Kelita who put a tremendous amount of effort into this paper and who continue to advocate for Indigenous health across the country.

– Maddy Arkle (Meds 2018, Local Officer of Indigenous Health-Western)

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Untranslatable Words

Posted on 19 October 2015 by Vanessa DeMelo

Welcome to my first post for the Procrastination Compilation, which is intended to entertain you, the reader, and me, the sleepy clerk, as we all learn about things that have little or nothing to do with medicine. My first post is about untranslatable words- ideas condensed into a single word that has no single equivalent in the English language. As someone who learned English as my first language, and whose French language skills are fairly rudimentary, I tend to be functionally monolinguistic. That is until recently, with the happening of medical school. Have you ever felt as if trying to amass hundreds of new medical words into your vocabulary can be a bit like the sieve-and-the-sand metaphor that we remember all too well from Fahrenheit 451? Learning the language of medicine really is a voracious undertaking, but with repeated exposure our skill to use our calor, dolor, rubor, and tumor descriptors will come naturally (I sincerely hope).

In the meantime, here are fun new devices to express yourself more effectively; even for situations that you didn’t even realize needed it. Have ten of my pickings:

  1. Pisanzapra (Malay) – the time it takes to eat a banana
  2. Komorebi (Japanese) – the sunlight that filters through the leaves of the trees
  3. Hiraeth (Welsh) – a homesickness for somewhere you cannot return to, the nostalgia and the grief for the lost places of your past, places that never were
  4. Drachenfutter (German) – literally “dragon-fodder.” The gift a husband gives to his wife when he’s trying to make up for bad behaviour
  5. Karelu (Tulu) – the mark left on the skin by wearing something tight
  6. Jayus (Indonesian) – a joke so terrible and so unfunny that you can’t help but laugh
  7. Mamihlapinatapai (Yaghan) – a silent acknowledgement and understanding between two people, who are both wishing or thinking the same thing (and are both unwilling to initiate)
  8. Trepverter (Yiddish) – a witty riposte or comeback you think of only when it is too late to use. Literally, “staircase words”
  9. Resfeber (Swedish) – the restless beat of a traveller’s heart before the journey begins, a mixture of anxiety and anticipation
  10. Ubuntu (Nguni Bantu) – essentially meaning ‘I find my worth in you, and you find your worth in me.’ Can be very roughly translated as human kindness
  11. Poronkusema (Finnish) – the distance a reindeer can comfortable travel before taking a break
  12. Tretår (Swedish) – on its own, “tår” means a cup of coffee and “patår” is the refill of said coffee. A “tretår” is therefore a second refill, or a “threefill”
  13. Ya’aburnee (Arabic) – meaning “you bury me”, a beautifully morbid declaration of one’s hope that they will die before another person, as it would be too difficult living without them

So I lied, and you ended up with a baker’s dozen worth of words. I couldn’t resist and I am not sorry in the slightest!

Credit goes to the book Lost in Translation, An Illustrated Compendium of Untranslatable Words from Around the World by Ella Frances Sanders (Ten Speed Press 2014). This little gem was a spontaneous purchase during exam season which I found via Twitter, of all places. Each word is accompanied by a whimsically wonderful illustration, and if you’re looking for an impulsive buy, I recommend it!

I also want to give a quick shout out to the Magoosh Vocabulary Builder App, which is a remarkably nerdy yet fun resource to quiz yourself and build that mental lexicon.

Happy October, and might you enjoy every last bit of pumpkin spice and seasonal feuillemort (having the colour of a faded, drying leaf, French).

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The Osler Society’s First Meeting & My History Project for the Year

Posted on 15 October 2015 by Rob Bobotsis

The Osler Society (Schulich’s History of Medicine Interest group) had our first meeting of the year recently. This is my second year as a member and the meeting was conducted in a very similar manner to last year’s gathering. As was done last year, we discussed the first chapter of Dr. Jacalyn Duffin’s History of Medicine: A Scandalously Short Introduction. However, with a sizeably larger group full of new faces, I found that the discussion took a much different path. One idea in particular stayed with me after I left the meeting, namely whether it is the medical invention or the inventor(s) that is more significant. I think one can find the inventor more interesting than their invention (and vice versa), but both are necessary for medical progress and therefore equally as important in my view.

Dr. Paul Potter and Dr. Shelley McKellar are faculty who we are very fortunate to have join us for Osler Society meetings. They asked if one can we really attribute an invention to one “great mind?” There was a resounding “no” to that question; rightly so in my opinion because no idea is created in a vacuum. There are so many external influences affecting how people think, behave and create. All this talk about innovation also had me thinking about how medical innovations, due to their inherent direct impact on human health, can be so controversial. Whether or not something is an innovation is hugely defined by the acceptance of the general public who will be subjected to a new drug, surgery or treatment modality. As I thought more about this idea, perhaps one of the most polarizing branches of medicine came to my mind, namely homeopathy.

I am no stranger to complementary and alternative medicines primarily through the influence of my father. He depends on insulin to live, yet strangely condemns modern medicine (I was there for his proclamations of the nescessity of iodine, then there was the salt craze and of course the importance of “earthing”).

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I know of homeopathy more so through friends and neighbours who are patients of homeopaths, but I also do quite a bit of independent researching on my own. I believe it is important to know about other treatment modalities as physicians because we have to be informed in discussions with our patients. Otherwise, our lack of knowledge as perceived by patients will negatively impact the relationship.
Homeopathy was created by Dr. Samuel Hahnemann (born in Germany in the mid-18th Century). He graduated from medical school and within 3 years of practicing he decided that he had a problem with the way medicine was being conducted. In particular he could not accept the practice of bloodletting because he thought it was too extreme. So, he decided to switch careers and became a translator. While translating Materia Medica, a treatise written by 18th century Scottish physician Dr. William Cullen (1710-1790, Professor of Medicine at Edinburgh), Dr. Hahnemann disagreed with Dr. Cullen’s explanation of how Peruvian bark (the source of quinine use to treat malaria) functioned. Hahnemann decided to experiment on himself by ingesting the bark, after which he experienced malaria-like symptoms (fever, diaphoresis, nausea etc). Hahnemann concluded therefore that a substance that causes a symptom in a healthy person will cure that same symptom in an ill person because the Peruvian bark, used to treat malaria, caused the same symptoms in a healthy person (himself). Hahnemann went on to test this principle by ingesting other substances, and whatever symptoms they caused he proclaimed they were also a cure for and from these tests Hahnemann devised the first rule of homeopathy, which is that “like cures like”.

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For the longest time I have wondered how this branch of medicine survived and more importantly has thrived for over 200 years to the present day. I have decided to dedicate my history of medicine project for the year to this end and that is what I am finally going to find out. Am I biased? Of course, but I am definitely open-minded enough and have a genuine curiosity to learn more. That is my history of medicine project this year, what are you curious about?

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Family Medicine & Public Health Around the World: What can we learn from Iran’s behvarzans?

Posted on 15 October 2015 by Jessica Bryce

Family doctors are keen on giving the best care to their patients. Public health is keen on maximizing the health of the population. Here in Canada, public health can sometimes seem like a separate entity from family medicine. Patients will tell you that public health tells us to immunize our children, breastfeed our babies, and shut down restaurants that don’t meet standards. Family doctors are the ones that you see when you get sick, for medication review, and for annual checkups.

However, the worlds of family medicine and public health are far more intertwined than it seems from the outside. How could we better integrate primary care and public health? Does Canada do it the right way? To answer this question, we need to look at how primary care and public health are coordinated around the world. Each blog in this series will feature a brief look at how it’s done in another country. In this series of blog posts, will look at how the integration of family medicine and public health differs vastly around the world.The final blog post will feature a summary of what we can learn from other nations.

In Iran, community health workers are called behvarzan (from the Farsi words ‘beh’ – good, and ‘varz’ – skill). Individuals from a community are trained to provide basic health care to their surrounding community. Often, a husband and wife will work together to accomplish this. They work in ‘health houses’ and provide services such as vaccinations, administering medications, child/maternal health, and ensuring proper water sanitation, among other things. There are over 1,400 health houses serving the rural population in Iran. Each of the health houses report and refer to a rural health centre that is staffed by general practitioners and other health care professionals. The program began in 1981. Since then, Iranian public health has improved substantially. Immunization rates have tripled, infant mortality rates have been halved, and family planning has been transformed. The health houses have been so successful that the concept has now been modified for Iran’s urban communities.

Check out more about Iran’s behvarzans here: http://www.who.int/bulletin/volumes/86/8/08-030808/en/

References:

  1. http://www.who.int/bulletin/volumes/86/8/08-030808/en/
  2. Panel discussion: “The Intersection of Family Medicine and Public Health Around the World”. http://livestream.com/SchulichSchoolofMedicineandDentistry/

“The family physician cares for the individual within the context of the family, for the family within the context of the community, and for the community in the context of public health, irrespective of race, culture, or class” – WONCA (World Organization of Family Doctors)

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The Fiddler and the Fire: The Decline and Fall of The Health Care System

Posted on 15 October 2015 by Adam Kovacs-Litman

The Ancient Roman Empire did not fall in a day. And it certainly didn’t fall because barbarians were knocking at the gate. The decline and fall took hundreds of years while ignorance, apathy and conceit ate away at the soul of empire. Rome rotted from within.

The Canadian health care system is critically ill. We are faced with a rapidly aging population and health care expenditures that consistently rise faster than both the rate of inflation adjusted for population and provincial government revenues. The writing is on our crumbling walls. The signs are all around us. The Canadian health care system is fundamentally unsustainable, yet we shrug our shoulders and trudge on with the confident irreverence of Ancient Rome.

The Liberal Government of Ontario addressed this problem of unsustainability by conjuring the wisdom of charlatan economists. As health care expenditures continue to grow, the government will cut $580 million over two years while demanding that physicians shoulder the burden of increased health care costs through claw backs and reconciliation. An additional 1.3% cut was just announced September 2015, raising total cuts to 6.9% plus reconciliation and inflation. The situation is even worse for family practitioners, particularly new graduates who will be barred from joining Family Health Organizations. Year after year, health care costs will continue to rise. A policy of reconciliation cannot by definition provide a meaningful long-term solution. The government’s unilateral action demonstrates an unwillingness to engage with the Ontario Medical Association (OMA). The Emperor refuses to heed the advice of the Senate.

The OMA has responded with an official policy of public advocacy and awareness. It is well intentioned, but perfectly obvious to all involved that this tact will fail to produce political dividends. Despite its low likelihood of leading to policy changes, some physicians may be appeased by the OMA’s actions. Unfortunately, one can hardly blame the OMA. What else is there for an organization lacking the means to exert any form of meaningful recourse? What else is there but bread and circuses?

This is not a policy brief advocating for any particular kind of action. This is instead a prophecy for Canadian health care. Rome will fall. This article is interested in how it will fall and what will rise from the ashes.

Our public access health care system is one of the biggest misconceptions surrounding the Canadian identity. Canadians pride themselves on the grandeur of our system and mock the Americans for the inefficiencies in theirs. We support the idea of our health care system with a religious devotion, making it immune to critique and impervious to logic. It is almost humorous, that for all our zealotry, the Canadian health care system is one of the worst of any developed nation. Many other countries have much more extensive public systems, offering coverage for optometry, dentistry, home care and pharmaceuticals while costing much less. Dramatic structural changes to the Canadian health care system are not only inevitable, but will likely prove advantageous in the long run.

As doctors gain more public support and the economic benefits of further pay cuts become marginal and untenable, the government will abandon this plan of attack. Instead, the government will scour for cost savings within the health care system. It will find some, particularly within hospitals stifled by expensive bureaucracy, but not enough to offset ever growing health care costs. Next, we will see funded services be cut with increasing frequency in a fruitless effort to stave off costs. It will begin with simple blood tests that few notice missing before progressing to increasingly important treatment options. This is already happening in the United Kingdom, whose health care system shares a similar plight (though perhaps for different reasons). In January 2015, the NHS defunded 25 cancer treatments, cutting short the lives of approximately eight thousand patients. When philosophical grumblings about health care became hard realities faced by baby boomers entering the latter part of their life, health care will become a national issue. The defunding of important services, a decline in the quality of care and even longer wait times are not acceptable when you are in your 70s, 80s, 90s or beyond.

When health care becomes the election issue, each party will present their own vision for what health care ought to be and none will resemble our current system. Variations on similar ideas will emerge throughout the provinces. Hospitals will receive considerable pay cuts as non-hospital medical centers like long-term care facilities receive increased funding. Health care will finally become more distributed with hospitals losing their stranglehold over the heart of medicine. Regulations surrounding billing will gradually loosen as the government embraces elements of the free market. Physicians will begin to splinter off from the public system, resulting in more private practices and clinics. Health care will continue to grow at a rate that exceeds inflation, but this growth will be largely financed by entrepreneurs and willing members of the public without depleting government coffers.

Health care will slowly become sustainable, unfortunately first it will burn.

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Physician Character and Integrity

Posted on 16 August 2015 by Lester Liao (Meds 2016)

Our last post discussed the significance of the oath in Hippocratic medicine and the importance of governing deities to ensure its terms were held.  While colleges serve a similar role in today’s world, the question remains: what if physicians can get away with things without the college noticing? This is where the content of the Hippocratic Oath begins to reveal much of the physician’s character.

Theoretically, in today’s society, if the college does not know you are somehow doing something unlawful and patients never complain, you can get away with anything.  This differs from the Hippocratic worldview that believed in gods that would certainly know what you were up to.  Embedded in the oath was a sentence of punishment for failing to uphold the oath.  Today this punishment may be losing the right to practice medicine.  Yet the college is not omniscient, and doctors today can certainly get away with small, “under-the-radar” practices that could relate to increasing financial gain, poor treatment of patients, and so on.  How is this to be prevented?  Hippocrates, on top polytheism, believed the solution was character.

As mentioned in previous posts, the Oath highlights a serious devotion to medicine and practicing it a certain way.  This assumes already that there is character compatibility between the practice of medicine and the person.   What is less obvious, however, is that this character is to be pervasive.  It is not what we would call “professionalism.”  Physicians were not to act all proper with patients but then to engage in all sorts of shenanigans on their own time.  Physicians were to be proper all the time.  Consider that the physician was to be “pure and holy both [in] my life and my art.”  This was hardly what we call professionalism.  This was integrity.  A physician was always to be a certain kind of person, never fragmented by circumstance or setting.  Regardless of surveillance, monetary gain, personal reputation, or simple convenience, physicians with integrity would act the same way.

The Oath further offers a practical example of how this integrity is supposed to manifest.  Regardless of whether the physician heard something inside or outside of the medical setting, he or she was never to divulge “what should not be published abroad.”  This was an early sort of confidentiality, but it was a confidentiality that developed not as an external restraint but as an internal disposition.  In today’s setting, if a physician is a terrible gossip but maintains patient confidentiality, there are no issues.  The Hippocratic worldview, however, did not hold such a disjointed view of the person.  The activity of the physicians developed from their fundamental characters.

When we consider today how to expect physicians to practice ethically, there are two things we can consider.  First we can ask if the person believes that there are true and real consequences to all his or her actions (even if they can somehow eschew human authorities).  Secondly we can ask what the physician is like as a person.  Surely it comes more naturally to a righteous person to act righteously in the professional and personal settings than for an unrighteous person to act righteously in the professional setting (presumably due to external rules and regulations) while acting unrighteously in all other domains.

We would do well today to learn this lesson from Hippocrates.  The human is a cohesive being that cannot arbitrarily be split into two personalities.  For all actions stem from a person’s heart or core.  Certainly we still have high aspirations and character qualities we laud in theory, but to the average patient seeing a community physician with little surveillance, integrity could be all the difference.   Perhaps recognizing the importance of a high devotion to medicine paired with personal integrity would change the way medicine is practiced today.

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