B.C.’s failed health-care experiment

Other provinces have opted for the team approach to solve the growing problem of patient access to doctors. Not in B.C. The team approach is not new. Roy Romanow recommended it in his 2002 report:

NorKam Medical Clinic (Google street view)

NorKam Medical Clinic (Google street view)

“in view of …changing trends, corresponding changes must be made in the way health care providers are educated and trained. If health care providers are expected to work together and share expertise in a team environment, it makes sense that their education and training should prepare them for this type of working arrangement.”

B.C. decided to keep doctors in their silos and try monetary reward.

B.C.’s experiment has failed, according to a report published in the Canadian Medical Association Journal. The report’s authors, Kimberlyn McGrail and Ruth Lavergne, professors at UBC and Simon Fraser University, respectively, wrote of their results in the Globe and Mail (August 17, 2016). Taxpayers have paid $397 million on the plan without much to show for it. Here’s how it was supposed to work.

The plan, called the Complex Care Initiative, was negotiated between the government of B.C. and doctors a decade ago. It gave doctors who treated patients with complex health problems an extra $315 each year per patient.

The rational was that if doctors cared for patients who were really sick, rather than those with minor complaints, the rest would go to a walk-in clinic. Dr, Shelley Ross, co-chair of the General Practice Services Committee, says that a doctor’s time is sometimes taken up with minor complaints, sometimes more serious. It could be a runny nose and sore throat or it could be case of diabetes, stroke, high blood pressure, and memory loss.

“So you can see the difference,” said Dr. Ross, “It is basically a time issue, it is not a knowledge issue. It’s not that we don’t know what to do, it’s just a matter of being able to spend the time to do the quality of care (Globe and Mail, August 15, 2016).”

While doctors understandably want to direct more attention to those in dire need, more walk-in clinics haven’t happened.

The failure of planning for clinics has left patients out on the street. I know, because last year I was one of them. Last year when my doctor was on vacation and I had an eye infection, I only got into the clinic on Tranquille with great persistence and intervention from the pharmacist next door.

Kamloopsians are expressing their concerns on social media. On Tuesday of this week, Megs (‏@PirateMeghan) tweeted “The walk in clinic doesn’t open til 8am and I’m waiting in a line up of 28 people outside. The need for doctors in #Kamloops is intense.”

I’m lucky to have a doctor. Tens of thousands of Kamloopsians don’t according to former city councillor Nancy Bepple: “Which is why it is no surprise that studies have reported between 15,000 and 30,000 people in Kamloops don’t have a family doctor. That is, between one in three and one in six people don’t have a doctor.”

The B.C. Liberal plan has left us with a shortage of doctors, overcrowded clinics, and no improvement in health care. Some plan.

PSA tests for prostate cancer are useful

Tests for prostate-specific antigen may not be perfect but in my case, results helped identify my prostate cancer. A sudden rise in my PSA levels was the first alarm to indicate that further testing was required.

PSA

All kinds of things affect PSA results: age, ethnicity, medications, inflammation, benign enlargement of the prostate gland, lab variability, and body mass index.

Despite being flawed, PSA results are worth paying attention to. That’s not the message that men have been getting because over-reliance on the tests can result in over-treatment. The United States Preventive Services Task Force came out against testing for PSA in 2012.

The Canadian Task Force on Preventive Health Care followed in 2014 with similar concerns that the PSA tests were too unreliable and heightened the risk of overdiagnosis, unnecessary follow-up, and treatment.

The warnings never made sense to me. We are told that early detection leads to the best treatment for cancer. Yet, the advisory groups said that such screening was unlikely to save many lives and would lead many men to undergo harmful surgery or radiation that could make them impotent or incontinent.

That may be true when PSA tests are the only indicator. Too many men, and their doctors, rely on PSA tests as conclusive. I think that’s especially true in the U.S. because health is a marketable commodity, not a universal right. If you can pay for treatment and if there are doctors looking for patients, supply and demand will dictate treatment. In a market-driven health care system, treatment is preferable to doing nothing.

Yet, doing nothing is a reasonable option. It’s called “watchful waiting” and it was offered to me by my doctor as an option. Doing nothing is more likely to happen in Canada where the opposite market conditions exist: doctor supply is low and the demand in our universal system is high.

I was encouraged by a study in the Canadian Medical Association Journal where the response to PSA tests is more nuanced. Dr. Rodney Breau, senior author of the study and surgical oncologist at a Ottawa Hospital, says the PSA test is a valuable tool and that the potential risks overtreatment can be managed.

“Instead of throwing the baby out with the bathwater and just scrapping screening altogether, many people believe if we screen smarter and treat patients more appropriately…then we’re going to keep all those benefits of screening and really significantly reduce potential harms that might be associated with it,” Dr. Breau told the Globe and Mail.

In my case, watchful waiting was not an option. For one thing, my PSA levels were high and rising quickly. A rectal exam revealed my prostate was large and asymmetrical. The Gleason score on my biopsy was high (a test of how aggressive the cancer is).  The good news was that the cancer had not metastasized; it was contained in my prostate.

Unlike me, for most men who receive PSA tests watchful waiting is the best option. The CMAJ study showed that only 30 per cent of the subjects who monitored results required treatment. It’s worth paying attention but not as a sole indicator.