12.26.2013

after eight years, i have a less-than-ideal observation about ontario health care

Since moving to Canada in 2005, my experiences with Ontario's health care system have been extremely positive. Through the public system, my partner and I have been able to access health care whenever we needed it, in convenient and pleasant settings, at no cost - that is, paid for with our taxes. The quality of care has been at least as good, and often superior, to anything I experineced in the United States.

I love our public health care system, and I would love to see it expanded.* Single-payer, nonprofit health care is the only system that makes any sense.

When I fractured my foot, I experienced a flaw in the Ontario system for the first time. The consequences for me happened to be minimal, but many people are affected seriously, and negatively. And apparently, the flaw stems from attempts to improve the Ontario health care system.

Like many people, I had no idea that bones in my foot actually had fractured. I couldn't put any weight on my foot without excruciating pain, but it seemed impossible to have broken a bone doing essentially nothing! That day, I continued to limp on it, and iced it. The next morning, when the foot was swollen and purple, I realized something was wrong.

We waited about four hours at Urgent Care (which seems reasonable to me), got a temporary plaster cast, and was told to report to the fracture clinic the following day. At the fracture clinic (part of the hospital's outpatient services), I was seen by a technician, who removed the plaster cast, prepped my x-rays for the orthopedist, and even prepared the walking cast, knowing that's what the doctor would ask for. The clinic was a large room separated into cubicles by curtains. Every patient there was waiting to see an orthopedic surgeon.

The doctor came in, turned his head towards the x-ray for a split-second, told the technician to fit me in a walking cast, and continued on to the next patient. I am not exaggerating: the doctor was in my cubicle for less than five seconds. He glanced at the x-ray so quickly that I could hardly believe he saw it at all. He was in and out of the cubicle without breaking stride.

The technician explained the walking cast to me - when to use it, when I could remove it - and told me to book a follow-up appointment in six weeks.

That night, I was in quite a bit of pain and called the clinic to ask if I should be concerned. Someone answered my questions by phone, but I felt that a simple hand-out for patients would have been very helpful. Perhaps a few different variations of FAQs could cover most questions about fractures, saving staff time, saving patients concern, and potentially preventing patients from worsening their condition or even returning to the hospital unnecessarily.

The fracture clinic was extremely efficient; it was too efficient. Everything was so fast and bare-bones that I couldn't help but wonder if if quality was being compromised.

Six weeks later, back at the Clinic, I waited only briefly for another x-ray and another glance from a doctor. The technician told me to wear sturdy sneakers, and I was on my way.

Once out of the walking cast, I had painful muscle spasms in my calf and hamstring, and went for some massage. Before long, I also realized that six weeks of immobilization had badly weakened my injured ankle, already chronically weak. I knew I need physiotherapy and booked some appointments.

The physiotherapist told me that her professional community in Ontario is endlessly frustrated and upset by the outpatient fracture clinic. My experience was absolutely typical: blink and you miss the doctor's visit. In my case, the fracture was common and not complicated, and the diagnosis was correct.

But, said the therapist, in many cases patients are sent home without treatment... and when the pain doesn't go away, and they come back, they learn that the first doctor blew the call, missing a fracture.

In addition, said the therapist, patients are not given information on after-care, and no one suggests physiotherapy. This, of course, leads to slower and less complete healing.

But here's the most interesting part. The physiotherapist said that this assembly-line treatment is a result of the focus on reducing wait times. Hospitals are under so much pressure to reduce wait times and meet patient targets that quality is being sacrificed.

Reducing wait-times has been the over-riding goal of Ontario health care for several years. In the Canadian context, "wait-times" generally refers to waiting for treatment in hospital emergency departments, waiting for orthopedic surgeries like joint replacements, and waiting for cancer diagnosis and treatment. It does not mean how long you wait to see a doctor on the day of the appointment, as many USians think.

So it would seem that this aspect of our public health care has been a victim of its own success.

The answer, of course, is not privatization and it's not a two-tier system where people with means can opt out. The answer is a more fully-funded public system. In this case, the answer might be as simple as giving doctors five minutes more per patient.



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* We have prescription drug coverage and dental insurance through my partner's job (and might through my job one day, too). If we didn't have that, a hefty chunk of our income would go towards prescription drugs, and perhaps in that case we would buy a private insurance package. The absence of dental and prescription coverage is a serious heath care gap, especially as fewer and fewer jobs include benefits. I wonder how much more coverage Ontario could afford if corporate taxes were restored to 1999 rates? How many fighter jets would buy us universal prescription coverage?


14 comments:

Amy said...

I just wish we had your system.

Even having private health insurance doesn't mean a doctor gives you the time of day. Although I have been very lucky, it's largely because I pick my doctors very carefully---often, it's someone I know (the advantages of living in a small community) or a recommendation from someone I know. In the few cases where the doctor doesn't know me or someone else I know, I often experience a more typical rushed doctor.

Certainly my experience at the HMO years ago was similar to yours---assembly line medicine where doctors were penalized if they stayed more than the allotted time with a patient.

Anyway, how is your foot/ankle?? I hope the PT helped. I am fully recovered from my last ankle injury in September. I hope you are also.

laura k said...

"I just wish we had your system."

I wish you did, too! It's amazing.

We always had HMO insurance and I don't think what I experienced at the fracture clinic was like that. With an HMO I saw a single doctor in an office. There was a financial disincentive for treatment, so the doctor was often not as thorough as they should have been. Here, I never find that. My doctor takes every precaution, always runs a test if there's a chance of a need.

The pressures on the fracture clinic aren't about profit. I'm sorry to learn that the wait-time reduction strategy has resulted in this other kind of pressure.

I'll take nonprofit health care over that any day.

Glad to hear your ankle is fully recovered. The physio does help a lot, and I continue to work on it. But my original injury dates back to 1999, plus I have problems with my joints, they are less stable and take longer to heal.

Amy said...

I agree with you, but given the ridiculous fear tactics people have bought into about Obamacare, we are lucky if we get anywhere with health care reform. (The incompetence of the government in its roll-out certainly hasn't helped.) The idea of a true single payor non profit system is just a dream here.

I must say despite the fact that each time my ankles have healed well, I live in fear of the next time I roll my ankle. I refuse to wear anything but safe shoes with good support, and I walk very gingerly on wet, icy and gravelly surfaces. Good luck with your continued healing.

laura k said...

"I live in fear of the next time I roll my ankle."

I know just what you mean. In fact that fear helps weaken our ankles.

Amy said...

How does the fear weaken our ankles? By making us use them less? Or something more specific than that?

laura k said...

When we walk more gingerly, we reduce something called proprioception - knowing where our bodies are in space. We get this from our feet sending signals to our brain. As we baby our ankles, our brains get decreased information from our feet, making us more likely to be off-balance... which further reduces our proprioception, in a cycle.

That's why physio for a foot or ankle injury includes standing on one foot, and when you graduate to it, standing on one foot with your eyes closed. It's building up your body's proprioception.

I learned this all in physio!

Amy said...

I was also taught to do the same in PT, though no one explained why---just said it would "strengthen" my ankle and help my balance. I was good about doing it on my own for a while, but then just forgot. Every time I hurt my ankle, I start doing it again, and then I stop again...

I guess I should be more religious about doing it.

laura k said...

The Wikipedia entry on proprioception is pretty interesting, especially the "applications" section.

laura k said...

I don't see how you can do the proper exercises without physio. They're progressive, so once they become too easy, you don't know the next step.

At least that's been my experience. If I go to physio, even once every 3 or 4 weeks, then I do the exercises. If I don't go, I don't do them.

Amy said...

I was taught what to do at PT, but once my ankle was healed, I got lazy. I remember the series of exercises, and I did continue standing on one foot for increasing periods of time, first on the hard floor, then on a cushion or rug, then with my eyes closed. I just need to keep doing it, but lose the incentive once my ankle no longer hurts.

We don't get ongoing PT through our insurance, so after six weeks, I am on my own.

laura k said...

Perhaps it will be an added incentive to learn that that's exactly what causes repeated ankle injuries. People work on the exercises until the can walk well enough and the pain is gone, but the ankle is not at full strength, and it happens again. The therapist told me that straight off!

I'm paying out of pocket, too. That's what money is for, eh.

Amy said...

Yes, but you are smarter than I am! :) What you say makes perfect sense. I may be playing with fire. It's food for thought. Thanks.

Amy said...

Sorry for the mixed metaphors...

laura k said...

I'm also using the time in physio to work on the repetitive stress injuries to my hands, arms, and neck. I don't go very frequently, but it helps keep me on track with the exercises.