Prescriptions of the past won’t fix modern health care
Published On Mon Jul 26 2010. Dr. Harvey Schipper, Mark Sarner
The symptoms are everywhere. When it comes to health care, Canada has become sick with the disease of “magical thinking.” Most recently the TD Economics report, building on the premise that health care is unaffordable and unsustainable, directs our attention largely to old supply management priorities.
The Ontario government was only the first to constrain generic drug costs at the expense of pharmacies. Pay-for-hospital performance will determine CEO pay, deemed too high. The trend to remove the influence and voice of doctors from health system management continues apace.
Mental health professionals define this approach as “magical thinking,” taking views and making decisions based on a defective perception of reality. The defective perception here is that what ails health care is fiscal; the “magical thinking” that the solution is to bring “efficiency” to the system.
Today’s concepts of health care are little more than bigger, more expensive, “modern” versions of what we conceptualized at the end of World War II. Not true. Twice.
First, today’s health-care challenges are largely a result of public health successes in years and decades past.
Public health cleaned up our water, improved nutrition, immunized Canadians against polio, smallpox and other major diseases, got people to put on seat belts, stop drinking and driving, and stop smoking.
Better education and a burgeoning economy, key social determinants of health, did their part too.
Net, net, we live better, live healthier and live longer. Our current focus is on dealing with diseases that were once deadly and are now chronic — cancer, heart disease and diabetes.
Second, we’re learning how to regulate illness rather than cut it out or kill it. The greatest promise derives from our fast growing understanding of biology, driven by genetics, proteomics and the high-resolution technologies that allow us to begin to understand the inner workings of every cell.
This is nothing short of a fundamental reframing of medicine. Case in point: treatment for those at high risk of breast cancer. Now typically diagnosed in mid-life, tomorrow’s diagnosis will begin in childhood. That’s medicine in the 21st century. We need a health-care system designed to function effectively in this new era. We don’t have one.
Our new understanding of biology leads to new technologies, which come very quickly, and are rapidly superceded. Capital equipment that once lasted 10 years or more is passé in five. We currently can’t fully understand where new technologies fit, and how to phase them in. And out.
At a human resource level, no matter how many new doctors and nurses we train, or import, they will not be appropriate to our needs if we maintain the magical notion that they will work in the same way in the same structure.
Globalization matters in medicine beyond the realization that a SARS virus can be in China one day and in Canada the next. The new genetics creates individualized medicine such that to properly treat someone with distant ethnic roots we must understand their community of origin. People of different genetic makeup get different diseases and respond differently to treatments.
How do we get over our “magical thinking”? For starters we need to replace faulty perceptions with a clear vision of health care going forward. That vision must be based on understanding what biology and medicine will look like in 20 years, driven by new knowledge, technology and global demographics.
Second, we have to get back to basics in the health-care system. We have to articulate what we want, and be transparent about our dreams and limitations. The underpinnings of the old model need to be re-examined in that light.
Next we have to decide the role we as a nation will play in a series of profound discussions which will shape not only the health of our people, but the wealth of our nation. These discussions must be, as all great medicine has always been, driven by the right questions. For starters:
- How do we move from a fragmented institution-centred potpourri of health satrapies to a seamless, wall-less system where the individual patient is the focus?
- Can we master the information and distance technology that will make that possible.
- How do we train and remunerate health professionals to allow their roles to shift to meet the demands of the new medicine?
- How do we evolve our means of invention and commercialization such that innovators enjoy the benefits of their creativity and all citizens share in the benefits?
- How and where do we focus our energies in biological research? How much for basic science; commercialization; health-care delivery; evaluation?
This is where we need to put our money and our minds. It is an opportunity for Canada to step up to be creators of the new health vision. Budget concerns will prompt a much different response if our efforts are truly future-focused. They aren’t. Yet.
The way ahead is clear: invest in a transformative future that promises massive health, social and economic returns for all. The message of the present is compelling: We can’t afford not to.
Dr. Harvey Schipper is a professor of medicine at the University of Toronto Medical School and an oncologist at St. Michael’s Hospital. Mark Sarner is president of Manifest Communications.
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