Medical Politics

We can change the health care agenda in Canada

The following President Elect Address was delivered on October 4, 2003 by Dr. Robert M. Hollinshead at the rescheduled COA Annual Meeting held in Winnipeg, MB. We are pleased to share a print version of this speech with our Bulletin readers.

Ed.

• Honored guests

• Visiting presidents

• Fellow colleagues

• Ladies and gentlemen

Thank you, Dr. Bill Rennie, for the kind introduction. I am truly honoured to have been given the opportunity to serve as your President.

Some of you may remember a hockey player by the name of Doug Risebrough who played with the Montreal Canadians and the Calgary Flames. Doug was a neighbor of mine and our families continue to be friends. After retiring as a player, Doug went into management. Today, he is the General Manager of the Minnesota Wild.

Asked about the extraordinary success of his hockey club, Doug said one of things he has learned in life is that if you surround yourself with the best possible people “everyone looks better and the chances of accomplishing your goals are so much greater.”

As I take on the Presidency of the Canadian Orthopaedic Association, I also feel comfortable in the knowledge that the COA has a very good team. I look forward to working with

• our outgoing President, Dr. Bill Rennie

• the Executive

• the Board

• the Members

• our Societies across the country

• our CEO, Mr. Doug Thomson and his staff who have done an outstanding job on our behalf

There are my colleagues in Calgary - all of whom offer great support and wise counsel. In particular, Dr. Norman Schachar who has helped me on matters educational ever since I was his first clinical teaching fellow in 1979; Dr. Gerry Kiefer, my politically astute AMA Board colleague; and Dr. Nick Mohtadi, my first collaborator in clinical research.

Most importantly, I have my wife Susan and our children, Lawrence, Katie and Sara. I so much appreciate their love and support, and I thank them for it.

This afternoon, I want to talk about what we as orthopaedic surgeons can do to influence health care decisions. Medical schools and our specialty training prepared us clinically. What medical school and residency did not prepare us for are the different worlds of politics:

• The world of medical politics

• The world of health care politics

• The world of real politics - although dealing with governments can sometimes seem more surreal than real

Health reform is and always will be a work in progress as we strive for excellence on a global scale. Canada actually stacks up well on many of the international quality indices as measured by the World Health Organization and OECD comparisons – such as life expectancy. Also, when looking at the percentage of the population in good or better health, Canada leads most first world countries at 88%, just behind the leader – U.S.A. at 90%.

In the recent past, there have been several reviews of Canadian health care at both the federal and provincial levels.

During my time as President of the Alberta Medical Association, I had the opportunity to meet twice with Senator Michael Kirby as he led that examination of Canada’s health care system, and also I appeared before Roy Romanow when he held hearings in Calgary.

In his report, Senator Kirby emphasized care guarantees and physician shortages. Mr. Romanow did not focus on physician shortages, rather he keyed in on primary care renewal and made little mention of access to specialty care.

After looking at some data given to me by Hugh Scully, a Toronto cardiac surgeon and Co-Chair of Task Force Two, I was surprised to see the yearly net loss in migration at over 300 Canadian physicians from 1996 to 2001, which, of course, relates directly back to access issues for patient care. Further, at 2.1 per 1,000 population, the number of physicians in Canada is below the OECD average of 2.9 physicians per 1,000 population.

Benchmarks, standards, and access guarantees have always been priorities among orthopaedic surgeons but we need the resources, both human and physical in order to achieve them.

We also know that health care is expensive and we must spend wisely in order to have a sustainable system.

Upon reviewing Canada’s health care expenditure as a percentage of GDP, I noted that Canada spends 9.1%, UK 7.3%, Australia 8.3%, France 9.5% and the U.S.A. just over 13%. Owen Adams, the Chief Economist at the Canadian Medical Association, recently told me he believes that in five to ten years, Canada will reach the same level as the United States.

Let’s also look at government spending as a percentage of overall health care spending, both public and private. Public or government funding in Canada, at 72%, is below that in many other countries including Australia at 73%, New Zealand at 78% and the UK at 81%, where two-tiered medicine flourishes.

In other words, the private sector plays a bigger role in the Canadian health system than it does in those countries even through physician services are 98% publicly-funded in Canada. The reason is the significant role of the Canadian private sector in areas such as pharmaceuticals.

How much this will change in the coming years, and in which direction, is anybody’s guess.

So, how do we improve health care in Canada? And, what can we, as doctors, do to influence change?

Doug Smith, who is a friend and also a consultant on our new provincial Bone and Joint Health Initiative in Alberta, once told me that doctors fall into one of four categories:

1. Lifestyle

2. Business Minded

3. Traditionalists (the so called Marcus Welbys)

4. Income Maximizers

In trying to move forward with any initiative, it is important to recognize that doctors come from different perspectives. For some of us, being involved politically is how and where we can contribute.

Orthopaedic surgeons need to advance bone and joint health to the top of the health care agenda in every province in this country. And the Canadian Orthopaedic Association needs to encourage and to help our colleagues to gain influence.

But we don’t have influence just by the virtue of being great clinicians. We have to influence the decisions at a variety of levels and through a variety of venues. According to Doug Smith, decision-making can be viewed as a board game.

It depends on how you want to play the game. Players can choose which level they wish to play at. Many people are happy just to get out there and do their best according to the rules as they understand them. This is the most basic level of the game, and the one with the most players. It is also the one with the least influence and the least power.

The next two levels involve:

• Those who interpret and enforce the rules and make some judgment calls.

• Those who make the rules and who build the processes and the game’s infrastructure.

The last level, and the highest level ,is played by those who actually design the game. It is the level with the most power and the most influence. As physicians, we need to play at Level Four whenever we can.

A physician who is playing at Level Four is Dr. Philippe Couillard, from the University of Sherbrooke. I met him earlier this year when he was in Calgary, as he spent a day finding out how we deliver publicly-funded care through private providers. Dr. Couillard is a neurosurgeon and today, he is the new Minister of Health for Quebec. He is now in a position to influence design of the health care system.

Within the world of orthopaedics we often play at Level Four. But as we move into different arenas, it becomes more difficult to do so. The bigger the arena, the greater the degree of difficulty. My friend and fellow orthopod, Dr. Bob McMurtry, also played at the top level as Assistant Deputy Minister in the largest department of Health Canada and as Special Advisor to the Romanow Commission.

As President of the AMA, I met with the Premier twice and with the Minister of Health a number of times.

I still recall my last day on the job. On very short notice, the Premier invited a few of us to meet with him about a provincial bone and joint health programme. There was Dr. Cy Frank from Calgary, Dr. Don Dick from Edmonton, and myself. That meeting with the Premier was only one of many that Alberta orthopaedic surgeons have had with a host of politicians, administrators, civil servants, business leader and others.

I very much suspect that the cardiac surgeons have been engaged in similar endeavors because our provincial government is supporting two centers of excellence:

• Bone and joint

• Cardiac

  • The price tag is $125 million apiece in provincial money alone

Now, there are many excellent reasons to build these two centres from the point of view of patient care, standards, quality, education, and research. There are many ways to justify these initiatives from a clinical perspective.

But these centres didn’t happen “just because” - they make sense medically and clinically. Political activity was absolutely essential.

These centres also came into being because of the relationships and partnerships that were developed, not only with key health care administrators, but also with key people within the political system beyond the politicians. People like fund-raisers and donors - people to whom the Premier listens to.

In other words, we were playing at Levels Two and Three and to a certain extent, also at Level Four. We continue to play at Level Four. For example, under Dr. Don Dick’s leadership, the Alberta Orthopaedic Society is developing a proposal for a province wide bone and joint network that will take it beyond an institute. In other words, creating and designing the game.

In playing at Level Four, it helps to have credibility, and lots of it. Over the years, survey after survey always places physicians as among the most trusted groups in society along with nurses and police officers. At the bottom of the list are journalists and politicians.

The elected officials know this. They know that the public trusts physicians (and not them) when it comes to matters of putting patient’s first; through timely access, quality standards, benchmarks and safety.

This was brought home to me on New Year’s Eve 1988 as I arrived in Australia to do a six-month shoulder fellowship with Dr. David Sonnabend. I still have a copy of the newspaper article in the Sydney Morning Herald. The paper may be old and yellowed, but the message and the impact of the story are as fresh and as relevant as the day I first read it.

The headline was: “40 Rebel Surgeons Decide to Stay Out.” You probably would not be surprised to hear that the story was a dispute between government and orthopaedic surgeons over contracts and how the physicians could practice medicine. The story described the situation as, and I quote, “a political embarrassment for the Minister of Health.”

Along the way I have learned many important lessons, and I want to talk about four:

The first lesson is that you have to become active politically. The easiest and quickest way is with money. Attend fund-raising dinners and events, make donations to candidates and politicians.

About 18 months ago, Dr. Clive P. Duncan, our Immediate Past President, invited me to visit the University of British Columbia to give a talk entitled “Advancing the Orthopaedic Agenda - The Alberta Model.” In the audience that night was Dr. Paul Wright. Paul perked up when I mentioned $1,000 as the potential minimum donation per election cycle that is necessary to get an assured meeting with your MLA, or MPP, or MNA. As it turned out, Paul’s hospital was slated for closure. So, he went ahead and made the donation, and was able to get such a meeting. Paul believes that meeting helped reverse the decision to close his hospital in Vancouver, and today his hospital remains open.

The second lesson involves two questions that you must ask yourself:

• Does it make sense from a medical standpoint, and for the health care system?

• Does it make sense politically?

Too many physicians think that just answering “yes” to the first question is all that matters. Yes, it makes sense clinically and medically, and for the health care system. I would argue that getting a “yes” to the second question is just as important because unless it makes sense politically, a programme is unlikely to go ahead.

The third lesson I have learned is that we, as physicians, must always choose the high road in being advocates for our patients.

Dr. Cy Frank, my good friend and Chief, leads by example. He always puts patients first and he only advocates change when the result will clearly be improved patient care. But Cy also knows the value of politics and has arranged our two tables at the Premier’s dinner in Calgary over the last few years. There is no doubt this political action has been noticed.

The final lesson, and a most important one, is: do not be stingy with praise. Give people credit for decisions they have made - even if you may think they have taken too long or have not given you exactly what you want. It is very easy to be critical, but politicians remember those who will go to the media and say, “It was a good decision. It was a job well done.”

My message to you today is that orthopaedic surgeons can make a difference in the design, in the structure and in the delivery of health care.

Même si le processus semble avancer lentement, les politiques en Médecine peuvent avoir un impact sur la réforme des services de la santé

We can affect change, and we can effect change.

I would like to close my remarks with a few thoughts about someone who was very special, someone many of us knew, someone whom we all admired. We lost Dr. Sandy Kirkley suddenly in a tragic airplane accident last fall. Greatness and courage come immediately to mind when one thinks of Sandy’s life, her contributions and her achievements. I would like to tell you about a small part of her remarkable legacy.

Susan and I got to know Sandy two years ago when she and I were the only two Canadians at the International Congress of the Shoulder in Capetown, South Africa. Sandy had a passion for excellence in every aspect of her life. Dr. Pete Fowler, Sandy’s mentor and a legend in Canadian orthopaedics himself, told me that early on in her career she said:

“We as orthopaedic surgeons need to rise to the challenge of designing and implementing clinical trials that provide the same level of evidence in support of treatments as our non-surgical colleagues demand.”

In that spirit, and with that attitude, she started, and was the founding president of the Canadian Shoulder Study Group, which is based on the multi-centre model that Canadian orthopaedic trauma surgeons pioneered.

Many surgeons from across Canada are collaborating on several randomized clinical trials. This small part of Sandy’s legacy was recently renamed JOINTS Canada which stands for Joint Orthopaedic Initiative for National Trials on the Shoulder.

We will endeavor to carry on with the initiative she began, and to recognize the importance of collecting evidence on surgical treatments and using it for solid evidence based decision-making.

Dr. Sandy Kirkley was an incredible role model for us all - men and women alike.

Merci beaucoup. Thank you for your attention. We all look forward to seeing you at the next COA Annual Meeting in Calgary next June.