Bad things come to those who wait
Monday, 22 November 2004
Mark Steyn
What's the defining characteristic of a government health service? It's one word, a word that, in its medical context, doesn't exist south of the border--"waiting," as in "waiting list," "waiting times," waiting, waiting, waiting.
I was sick over the summer and, down in New Hampshire, I went to see the local doctor, who referred me to a specialist. Let's just run through that manoeuvre again, in case it happened too quickly for those accustomed to Quebec levels of treatment: I saw the GP on Tuesday, got referred, saw the specialist Thursday. As is often the case in the U.S., the doctor was Canadian, and indeed came from a long line of Canadian doctors--both his parents practise in Ottawa. Making idle chitchat as his fingers felt his way around my fleshly delights, he explained that "waiting" is built into the concept of a government health service: "If you need surgery," he said, "it's in my interest to get you in and operated on as soon as possible, because that's money for me. The faster it happens, the better my cash flow. But when the government runs the system, every time you get operated on it costs the government money. So it's in their interest to restrict or delay your access. When you look at the overall budgets--salaries, buildings--it's not hard to understand that the level of service you provide to the patient is one of your few discretionary costs. So the incentive is to reduce that."
He was chuckling merrily as he explained this, and I got the feeling he'd said it to many Canadians over the years. Defenders of our system often point out that America spends a higher proportion of its GDP on health care than Canada and yet has lower life expectancy. I'm not sure I quite understand the point they're making. I have employees on both sides of the border. When my assistant in New Hampshire has a doctor's appointment at 9 a.m., she's in his office by 9:07 and back in my office by 11. My assistant in Quebec, living in a jurisdiction with the lowest doctor-patient ratio in the western world, can't get a doctor's appointment, so she goes to her local CLSC at 9 a.m., and waits, and waits and waits and waits all day to be seen.
I doubt Chantal's and my loss of economic activity is factored into those health-care-as-a-proportion-of-GDP costs. In Canada, we accept that if you get something mildly semi-serious, it drags on while you wait to be seen, wait to be diagnosed, wait to be treated. Meanwhile, you're working under par. The default mode of the system is to "control health care costs" by providing less health care. Once it becomes natural to wait six months for an MRI, it's not difficult to persuade you that it's natural to wait 10 months, or 15. Acceptance of the initial concept of "waiting" is what matters.
The other week, I made some remarks about C. difficile in The Chicago Sun-Times and observed that it was caused by inattention to hygiene--"by unionized, unsackable cleaners who don't clean properly; by harassed overstretched hospital staff who don't bother washing their hands as often as they should." Michael Miner, in the city's "alternative weekly," The Chicago Reader, took exception to this, mainly because, in a clean American convalescence home, his mother had contracted C. difficile and died. He has my sympathies. I'm not sure that it's wise to trash my argument purely on personal experience, but, since he brought up his mother, let me bring up my wife.
A few years back, she felt herself beginning to miscarry. Nobody was at home so she called a cab and went to the emergency room at the Royal Victoria. Knowing what "emergency" means in the Quebec system, she grabbed a novel on the way out--an excellent choice, Mr. Standfast by John Buchan, our late Governor General. It's 304 pages, and my wife had the time to read every single one of them before any medical professional saw her. While she was reading, she was bleeding, all over the emergency room floor, the pool of large dark red around her growing bigger and bigger, until eventually a passing cleaner ran her mop over the small lake and delivered a small rebuke to my wife for having the impertinence not to cease bleeding.
Maybe it was just bad luck. Michael Miner at The Chicago Reader got U of T's John Marshall on the phone to assure him that "Canadian medical standards are on average every bit as high as American medical standards. It has nothing to do with the structures of the health care system." Oh, really? If Miner's mother was dissatisfied with her convalescence home, she could always pick another. And don't give me all the fine print about HMOs and co-payers: in the last resort, you or your loved ones can always reach into your billfold and go anywhere you can afford. At the Royal Vic, no matter how many bills you wave around, you still have to bleed all over the floor because they're the only game in town. Universal lack of access. Equality of crap--very literally, as the C. difficile outbreak demonstrates.
Since my wife's experience, the average wait time in Montreal emergency rooms has apparently gone up to 48 hours. So don't pack an overnight bag, take two, and the complete works of John Buchan. The natural consequence of a system built on waiting is that more people do what she did--sit in the hospital, waiting to be seen, bleeding all over the floor until a cleaner (and it's one cleaner per two floors at many Montreal hospitals) wipes it up with a dirty mop and then runs the same mop over the floor in the isolation ward upstairs.
That's the C. difficile story. That's why the fatality rate in Montreal is four times (officially) the North American average. "In many institutions, housekeeping staff has been reduced while nursing workloads have increased," reports Quebec's Clostridium Difficile-Associated Diarrhea Clinical Study Investigators Group. "Compliance with hand hygiene has been shown to decrease as workloads increase . . . Wards and emergency departments have become more crowded, and bed turnover is rapid. This makes containment of C. difficile exceedingly difficult, especially among patients with fecal incontinence." According to Dr. Louise Poirier of the Quebec microbiologists' association, "It's not that easy if you are a nurse and you have six patients. You take your gloves off and you go far away, find a sink, wash your hands, go back, put on another gown. You do that sometimes 20 times in an afternoon."
Hygiene is the number one issue in Canadian hospitals, and a problem with hygiene is the logical consequence of a system built on "waiting." On March 7 last year, Tse Chi Kwai went to Scarborough Grace Hospital and, as is traditional, was left on a gurney in emergency for 12 hours, exposed to hundreds of people. Two days earlier, his mother had died of SARS but, despite displaying to her doctor all the symptoms detailed in the several health alerts on the subject, had cause of death listed as "heart attack." And at Scarborough Grace, even after discovering that Tse's mother had recently died after returning from Hong Kong, Dr. Sandy Finkelstein concluded that, even if Tse was infectious, it was only with TB. Lying next to Tse on that ER gurney hour after hour was Joe Pollack, who was being treated for an irregular heartbeat. He was subsequently sent home but returned on March 16 with symptoms of SARS. He was admitted and isolated, but apparently it never occurred to the hospital to isolate Mrs. Pollack. So she wandered around the wards and infected an 82-year-old man from a Catholic Charismatic group.
Mr. Pollack, Mrs. Pollack, the 82-year-old Catholic Charismatic and his wife all died. None of these people went anywhere near Southeast Asia. They were exposed to SARS by the Toronto health care system, as was the 82-year-old's son, who was also unknowingly infected at Scarborough Grace and went on to expose another 500 to SARS at a religious retreat. As I wrote in the National Post at the time, "Only in Canada does the virus owe its grip on the population to the active co-operation of the medical profession. In Toronto, the system that's supposed to protect us from infection instead infected us. They breached the most basic medical principle: first do no harm."
Almost all scandals in Canadian hospitals boil down to the same thing: a decrepit system unable to observe basic rules of hygiene and quarantine. Sometimes it's SARS, sometimes it's C. difficile, sometimes it's hundreds of women going in to the Captain William Jackman Memorial Hospital in Labrador City and being gynecologically examined with unsterilized instruments-and thereby potentially exposed to chlamydia, gonorrhea, hepatitis or HIV. And almost all these crises are due to, in Dr. Marshall's words, "the structures"--a system that ensures sick people wait longer in crowded rooms in dirtier hospitals will, by definition, spread disease.
One day it will be something much worse than C. difficile.
Monday, 22 November 2004
Mark Steyn
What's the defining characteristic of a government health service? It's one word, a word that, in its medical context, doesn't exist south of the border--"waiting," as in "waiting list," "waiting times," waiting, waiting, waiting.
I was sick over the summer and, down in New Hampshire, I went to see the local doctor, who referred me to a specialist. Let's just run through that manoeuvre again, in case it happened too quickly for those accustomed to Quebec levels of treatment: I saw the GP on Tuesday, got referred, saw the specialist Thursday. As is often the case in the U.S., the doctor was Canadian, and indeed came from a long line of Canadian doctors--both his parents practise in Ottawa. Making idle chitchat as his fingers felt his way around my fleshly delights, he explained that "waiting" is built into the concept of a government health service: "If you need surgery," he said, "it's in my interest to get you in and operated on as soon as possible, because that's money for me. The faster it happens, the better my cash flow. But when the government runs the system, every time you get operated on it costs the government money. So it's in their interest to restrict or delay your access. When you look at the overall budgets--salaries, buildings--it's not hard to understand that the level of service you provide to the patient is one of your few discretionary costs. So the incentive is to reduce that."
He was chuckling merrily as he explained this, and I got the feeling he'd said it to many Canadians over the years. Defenders of our system often point out that America spends a higher proportion of its GDP on health care than Canada and yet has lower life expectancy. I'm not sure I quite understand the point they're making. I have employees on both sides of the border. When my assistant in New Hampshire has a doctor's appointment at 9 a.m., she's in his office by 9:07 and back in my office by 11. My assistant in Quebec, living in a jurisdiction with the lowest doctor-patient ratio in the western world, can't get a doctor's appointment, so she goes to her local CLSC at 9 a.m., and waits, and waits and waits and waits all day to be seen.
I doubt Chantal's and my loss of economic activity is factored into those health-care-as-a-proportion-of-GDP costs. In Canada, we accept that if you get something mildly semi-serious, it drags on while you wait to be seen, wait to be diagnosed, wait to be treated. Meanwhile, you're working under par. The default mode of the system is to "control health care costs" by providing less health care. Once it becomes natural to wait six months for an MRI, it's not difficult to persuade you that it's natural to wait 10 months, or 15. Acceptance of the initial concept of "waiting" is what matters.
The other week, I made some remarks about C. difficile in The Chicago Sun-Times and observed that it was caused by inattention to hygiene--"by unionized, unsackable cleaners who don't clean properly; by harassed overstretched hospital staff who don't bother washing their hands as often as they should." Michael Miner, in the city's "alternative weekly," The Chicago Reader, took exception to this, mainly because, in a clean American convalescence home, his mother had contracted C. difficile and died. He has my sympathies. I'm not sure that it's wise to trash my argument purely on personal experience, but, since he brought up his mother, let me bring up my wife.
A few years back, she felt herself beginning to miscarry. Nobody was at home so she called a cab and went to the emergency room at the Royal Victoria. Knowing what "emergency" means in the Quebec system, she grabbed a novel on the way out--an excellent choice, Mr. Standfast by John Buchan, our late Governor General. It's 304 pages, and my wife had the time to read every single one of them before any medical professional saw her. While she was reading, she was bleeding, all over the emergency room floor, the pool of large dark red around her growing bigger and bigger, until eventually a passing cleaner ran her mop over the small lake and delivered a small rebuke to my wife for having the impertinence not to cease bleeding.
Maybe it was just bad luck. Michael Miner at The Chicago Reader got U of T's John Marshall on the phone to assure him that "Canadian medical standards are on average every bit as high as American medical standards. It has nothing to do with the structures of the health care system." Oh, really? If Miner's mother was dissatisfied with her convalescence home, she could always pick another. And don't give me all the fine print about HMOs and co-payers: in the last resort, you or your loved ones can always reach into your billfold and go anywhere you can afford. At the Royal Vic, no matter how many bills you wave around, you still have to bleed all over the floor because they're the only game in town. Universal lack of access. Equality of crap--very literally, as the C. difficile outbreak demonstrates.
Since my wife's experience, the average wait time in Montreal emergency rooms has apparently gone up to 48 hours. So don't pack an overnight bag, take two, and the complete works of John Buchan. The natural consequence of a system built on waiting is that more people do what she did--sit in the hospital, waiting to be seen, bleeding all over the floor until a cleaner (and it's one cleaner per two floors at many Montreal hospitals) wipes it up with a dirty mop and then runs the same mop over the floor in the isolation ward upstairs.
That's the C. difficile story. That's why the fatality rate in Montreal is four times (officially) the North American average. "In many institutions, housekeeping staff has been reduced while nursing workloads have increased," reports Quebec's Clostridium Difficile-Associated Diarrhea Clinical Study Investigators Group. "Compliance with hand hygiene has been shown to decrease as workloads increase . . . Wards and emergency departments have become more crowded, and bed turnover is rapid. This makes containment of C. difficile exceedingly difficult, especially among patients with fecal incontinence." According to Dr. Louise Poirier of the Quebec microbiologists' association, "It's not that easy if you are a nurse and you have six patients. You take your gloves off and you go far away, find a sink, wash your hands, go back, put on another gown. You do that sometimes 20 times in an afternoon."
Hygiene is the number one issue in Canadian hospitals, and a problem with hygiene is the logical consequence of a system built on "waiting." On March 7 last year, Tse Chi Kwai went to Scarborough Grace Hospital and, as is traditional, was left on a gurney in emergency for 12 hours, exposed to hundreds of people. Two days earlier, his mother had died of SARS but, despite displaying to her doctor all the symptoms detailed in the several health alerts on the subject, had cause of death listed as "heart attack." And at Scarborough Grace, even after discovering that Tse's mother had recently died after returning from Hong Kong, Dr. Sandy Finkelstein concluded that, even if Tse was infectious, it was only with TB. Lying next to Tse on that ER gurney hour after hour was Joe Pollack, who was being treated for an irregular heartbeat. He was subsequently sent home but returned on March 16 with symptoms of SARS. He was admitted and isolated, but apparently it never occurred to the hospital to isolate Mrs. Pollack. So she wandered around the wards and infected an 82-year-old man from a Catholic Charismatic group.
Mr. Pollack, Mrs. Pollack, the 82-year-old Catholic Charismatic and his wife all died. None of these people went anywhere near Southeast Asia. They were exposed to SARS by the Toronto health care system, as was the 82-year-old's son, who was also unknowingly infected at Scarborough Grace and went on to expose another 500 to SARS at a religious retreat. As I wrote in the National Post at the time, "Only in Canada does the virus owe its grip on the population to the active co-operation of the medical profession. In Toronto, the system that's supposed to protect us from infection instead infected us. They breached the most basic medical principle: first do no harm."
Almost all scandals in Canadian hospitals boil down to the same thing: a decrepit system unable to observe basic rules of hygiene and quarantine. Sometimes it's SARS, sometimes it's C. difficile, sometimes it's hundreds of women going in to the Captain William Jackman Memorial Hospital in Labrador City and being gynecologically examined with unsterilized instruments-and thereby potentially exposed to chlamydia, gonorrhea, hepatitis or HIV. And almost all these crises are due to, in Dr. Marshall's words, "the structures"--a system that ensures sick people wait longer in crowded rooms in dirtier hospitals will, by definition, spread disease.
One day it will be something much worse than C. difficile.
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