Front Burner - ‘Signs of collapse’ and ways to fix health care

Episode Date: November 21, 2022

There's a lot of bad news in Canadian health care. We're still in the midst of a pandemic, RSV and flu season are hitting families hard, and headlines across the country have been dominated by reports of staffing shortages, severe burnout, overrun emergency rooms, and long wait times for surgeries. Front-line health-care workers and patients are raising alarms about a system breaking under the pressure. Dr. Brian Goldman is the host of CBC Radio's White Coat, Black Art and CBC podcast The Dose. He's also an emergency physician in Toronto and has spent a lot of time thinking about the issues that plague the system. Monday on Front Burner, Dr. Goldman joins us to talk about possible solutions and why some in the field are worried about a health-collapse, rather than a crisis.

In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization, empowering Canada's entrepreneurs through angel investment and industry connections. This is a CBC Podcast. Hi, I'm Allie Janes, in for Jamie Poisson. lives. RSV and the flu along with COVID are hitting hospitals hard. I've never seen burnout and distress this high. It's a very serious threat to physician retention and recruitment. It doesn't matter where you are. All across the country, we're hearing about staffing shortages and severe burnout, about overrun emergency rooms, incredibly long wait times for surgeries,

emergency rooms, incredibly long wait times for surgeries, and a lack of access to key medications. It's hard not to think that the healthcare system in Canada is on fire. Dr. Brian Goldman is the host of CBC Radio's White Coat Black Art and the CBC podcast The Dose. He's also an emergency physician in Toronto, and he's spent a lot of time thinking about the issues that plague our system. So he's here with us today to talk about possible solutions and why some in the field are worried, not about a healthcare crisis, but a collapse. Hi, Brian. Thank you so much for making time for us today. Hi, Allie. So since the start of the pandemic, you know, we've all heard a lot about how the healthcare system is in crisis.

But I'm wondering if you think that that description goes far enough. Yeah, it's interesting. A few months ago, I started hearing the word collapse by people like Dr. Catherine Smart, who's the immediate past president of the Canadian Medical Association. And I thought, you know, that was the wrong term to use because collapse, you know, the word crisis is a matter of opinion. But collapse, you know, it's a visual metaphor that means something. It immediately makes you think of the collapse of the Soviet Union, you know, the collapse of the banking industry, the collapse of the financial markets. Our health care system, that's really struggling right now. And some of us have even gone to say we feel it's starting to collapse. We've got underwhelming electronic medical records. We have very poor data architecture and ability to either use data to drive accountability or outcomes in our system or to share information. We've got

growing backlogs, especially for things like surgery and diagnostic imaging across our system. Wait times are at an all-time high, and there is an epidemic of burnout amongst physicians and other healthcare professionals. I looked around and I wondered, do we see signs of collapse in the healthcare system? And increasingly, I've come to Catherine Smart's view that in fact, and I guess now Alika LaFontaine, who's the current president

of the Canadian Medical Association, I think there are signs of collapse, not everywhere, it's not homogeneous I think there are signs of collapse, not everywhere, it's not homogeneous, but there are pockets of it. There are provinces like Saskatchewan where there are almost no family doctors, we never say never, almost no family doctors who are taking on patients. And so we're going to end up with an increasing number of unattached patients. And so we're going to end up with an increasing number of unattached patients. You have emergency departments that lack adequate staffing where they're one nurse away, one nurse calling in sick or being unavailable or quitting from having anomaly that an emergency department closed down, that it was a never event, almost a never event. It's become almost a regular thing. You've got general internal medicine wards and critical care units that are chronically understaffed, forcing the people who are working there to work extra shifts, work overtime. There's mandatory overtime, overtime to the point of burnout. You've got large amounts of burnout. You've got provinces that aren't doing as much cancer screening,

haven't been doing as much cancer screening during the pandemic, and now they're inundated with people who, instead of having stage one cancer, have stage three or four cancer, and are waiting months to get a referral to an oncologist or get all of their diagnostic imaging. I mean, it can go on and on and on. I mean, in British Columbia recently, you know, on our show, on White Coat Black Art and also reported in the Globe and Mail recently, there are patients who are waiting so long for confirmation

of their cancer diagnosis that they're having made in the meantime. Oh, my God. I mean, that's horrifying. I mean, everything you're saying is honestly terrifying. Like it's awful. And on top of this, I mean, we know that this happens to be a really bad year for respiratory illnesses, right? I mean, we just did an episode the other week on kids with RSV filling up ERs. We're learning now that flu season has come early this year. There's a ton of it going around. The reason I'm speaking to you today is because our host, Jamie, is home with a really bad cough. She's lost her voice. She's fine. But, you know, it's just a sign of how prevalent this all is right now. So, I mean, as this all is compounding,

what are you seeing on the ground in the ER as an emergency physician? Like, what's the scene like right now? Yeah, and a lot of what I was talking about was happening before this incredible season for respiratory viruses. So, what are we seeing right now? Right now, the epicenter of the crisis, certainly in pediatric hospitals. Winnipeg's Children's Hospital had over 200 patient visits on Sunday alone, and hospital staff are being run ragged as respiratory viruses like RSV, COVID-19 and influenza are running rampant and spreading.

201 patients in one day is absolutely phenomenal. Dr. Jason Fisher is the division head of emergency at SickKids. And typically we would expect to see about 230 patients a day, but we're seeing well over 300. First of all, they have patient numbers where whatever they consider full capacity, they're at 130, 140, 150, sometimes 180% capacity. At hospitals like CHEO, they're opening up second ICUs, satellite pediatric ICUs, because they're inundated with patients with young kids who have severe respiratory infections. And some of them, even if it's just a small number, you've got such a large denominator that you end up with an oppressive number of kids who require ventilators.

That spills over. And all of the ramifications of that, you've got people being redeployed all over the hospital. You have adult hospitals who have to pitch in. I work in an adult hospital right across the street from sick kids. And, you know, it's no longer a surprise that we're seeing an increasing number of teenagers who are coming, parents bringing their younger kids to our emergency department because sick kids is inundated. All the pediatric hospitals that are affected are postponing really important heart surgery, brain surgery, spine surgery. That's important for the for the rest of that child's life.

And they're going to be missing milestones as a direct result of having that surgery postponed. And you can imagine how difficult it is for the people in those hospitals to have to call up parents and say, yet again, you know, the surgery is being postponed. Jamie, hope you feel better soon. I can tell you that I know so many people who have the worst flu that they've had in years. Fortunately, most of them won't require medical services, but some do, particularly frail seniors. And so we are seeing an ever-increasing number of people coming to the emergency department and having to be admitted with respiratory illnesses

or requiring treatment advice. So please wear masks and get your flu shot in addition to getting your COVID vaccine. I haven't even mentioned what's going on in the emergency department itself, and I'm an emergency physician. So much of what you're saying, Brian, is like, it's heartbreaking. I don't really have other words for it. Like, it's just so horrifying to hear. Even when we talk about trying to alleviate pressure on emergency rooms, you know, people are being told to use walk-in clinics and urgent care centers instead, to see their family doctor

when appropriate. But I mean, depending on where you live and like even in big city centers, you know, as you mentioned earlier, like a lot of people don't even have access to a family doctor. So what are the issues that have contributed to that? Like, you know, which otherwise would be a first line of defense here. And then there are short-term trends that are the direct result of the stress and burnout that was brought on by the pandemic. And now the respiratory infections that we're seeing may be exacerbating those even more. The longstanding problems are family physicians, that large cohort of baby boomer family physicians will eventually retire. In British Columbia, the predictions are that 40% of family physicians will retire in the next 10 years. So that's a freight train. That's a huge trend. In addition to that, I don't want to just talk about physicians, even though I am a

physician. Let's talk about nurses. Nurses have been leaving the profession or they've been moving from full time employment in hospitals, you know, on internal medicine wards, intensive care units and and emergency departments to name to name three. And then, of course, pediatric nurses as United States. Or they have switched to casual part-time working for an agency where they've discovered they can earn a lot more money and not have kind of the ongoing stress because they can pick and choose how much they want to work. And, you know, if they find that a certain hospital is a little too stressful for them, they can say, you know what, I'm going to take a pass on this one and you can find another hospital for me to work in instead. And more power to them. You know, we can't keep visiting stress on people. You know, there are nurses who have been forced because of agreements between their provincial union and the province to work four, five,

six days in a row. And, you know, on that sixth day, how palatable is it and how safe is it for them to be working a few extra hours of overtime, you know, at a time when they're exhausted and they really need to go home and rest. You know, you mentioned urgent care centers. Urgent care centers, you know, at one time in BC were considered the solution to unattached patients, you know, to help patients. Now they can go to an urgent care center if they don't have a family doctor. The problem with that is that the urgent care center model is based on seeing people, you know, for 10 minutes, 10 minutes a visit, 15 minutes of visits, probably generous,

you know, people who have urinary tract infections, blood pressure, concerned about their blood pressure. Maybe they have an ankle that needs to be taped up, you know, minor, minor conditions that are well suited to a 10 minute appointment. Not so if you haven't had a family doctor in 10 years and you've got bad heart disease and, oh, you've had a bit of chest pain, maybe it was indigestion. I went to the emergency department and I didn't want to wait eight hours,

so I signed myself out against medical advice. And now here I am at the urgent care center at 0800 and that family physician, maybe they can send them back to the emergency department or maybe they're going to spend an hour with that patient. And so that's the reason why wait times in urgent care centers in some parts of Canada have now topped five, six hours. And, you know, they close.

And when they close, so that means, you know, if they close at 7 p.m., they're going to stop registering new patients at 3 p.m. because they can't hope to see them all by 7 p.m. In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization. Empowering Canada's entrepreneurs through angel investment and industry connections. Hi, it's Ramit Sethi here. You may have seen my money show on Netflix. I've been talking about money for 20 years.

I've talked to millions of people and I have some startling numbers to share with you. Did you know that of the people I speak to, 50% of them do not know their own household income? That's not a typo, 50%. That's because money is confusing. In my new book and podcast, Money for Couples, I help you and your partner create a financial vision together. To listen to this podcast, just search for Money for Couples. Let's talk about money now because, you know, there's an ongoing fight over health care funding between the federal government and the provinces. I mean, I'm sure a lot of our listeners have probably heard this paging Dr. Persaud ad campaign from the premiers. There is a Dr. Persaud, by the way. Really?

Oh, yeah, there is. Yes. Oh, wow. I understand. Yes. Okay. Well, there you go. The more you know.

But I mean, you know, the provinces are demanding a larger investment from Ottawa. And the Canadian Medical Association also says the system really urgently needs an injection of cash. Association also says the system really urgently needs an injection of cash and that they're disappointed that the provinces and the feds haven't managed to reach a funding deal yet. I mean, how much of a sense is there in the health care system that the federal government really does need to step up here? You know, obviously, this is a question that has not only a health care perspective, but also has a political perspective. And if you look at the amount of the Canadian health transfer, more than $42 billion in fiscal 2021, and it was topped up. There was a one-time only top up.

You know, if that's the same number as the fix for a generation of Paul Martin going back, what, 15, 16 years, just considering inflation, although inflation wasn't that high most of the time, it's probably not as much as it should be. So I think it's fair to say that that's true. On the other hand, you know, if you look at how much Canada is spending per capita compared to other industrialized nations, we're middle of the pack. We're not right at the very bottom. We don't spend as much as the United States, but we actually spend more than Sweden. We spend more than Australia. We spend less than Germany. And there is a school of thought that we just aren't spending wisely. You know, we are spending the money, but we may not be spending it as wisely as we could. And maybe we need to redirect our spending to avoid duplication, maybe to have a different kind of health care provider instead of the most expensive kind of health care provider, which tends to be physicians.

money and healthcare costs money and you can't avoid that, especially with patients who have increasingly complex needs, the more we can do, you know, in terms of cancer treatment, treatment of autoimmune diseases like rheumatoid arthritis and, you know, Crohn's disease and managing people with chronic congestive heart failure, you know, it is going to cost more money, but we probably could be spending it more wisely. Okay, so that's a good segue into what I wanted to talk to you about next, which is solutions. Because, I mean, obviously this is like a pretty bleak conversation. I've used the words heartbreaking and terrifying among other descriptors, but we should also, you know, talk about possibilities of what could be done here. So,

I mean, are there examples of places in Canada that are piloting fixes right now that you're seeing to some of the issues that we've been talking about that you think could be helpful? Yeah, there are, fortunately. And let me give you a couple of examples that are here in Canada. There's also one outside of Canada that I think is worth highlighting. So right now, the hottest initiative that I think a lot of people should be paying attention to in Canada is what's going on in BC right now. Recently, the BC government and doctors of BC announced a complete revamping of the way family doctors in the province will be paid starting in February of 2023. A raise for family doctors in B.C., one of several changes the province has unveiled in a new compensation model to try to ease pressure on the health care system. It is by far the best agreement negotiated for physicians in Canada this year.

And I believe it is one of the best that has ever been negotiated here in BC. So instead of being paid their usual visit fee of 30 to 40 bucks, regardless of the severity of the patient's problem, family doctors will be paid based on the time they spend with patients, the number of patients they see in a day, the number of patients attached to their practice, the complexity of patients' needs, and their office overhead costs, they'll see increased income, and they will be incentivized to see more patients. And part of this new funding is that they will be paid, if they see more complex patients, they'll be paid more to see those complex patients. Now, If they see more complex patients, they'll be paid more to see those complex patients.

Now, you know the saying, God's in the details. We don't, like it hasn't been implemented yet. We know that any kind of system can be gamed to advantage. We hope that doesn't happen. But if this works, it will go a long way to keep family doctors happy in longitudinal or office-based practice. And that's where their, you know, where family doctors have been longitudinal or office-based practice. And that's where they're, you know, where family doctors have been leaving in droves. So that's one experiment. Another one is what's going on in the County of Renfrew, Ontario, Ottawa Valley, Algonquin Park, you know, people who live there, 20% of them don't have a family doctor. A lot of them are seniors. And in this sparsely populated part

of Canada, if they need care, they either have to call 911 or would have had to call 911 or have a loved one take them to the emergency department. Instead, they have a program in which they can call, if they're unattached, they can call a toll-free number and speak to a family doctor and then come into the office. Or if they're too frail and the family doctor thinks that they need to be seen in their home, a community paramedic can be dispatched to their home in a specially equipped vehicle, not an ambulance, to see them in their home, do a history physical, EKG, blood work, point of care, ultrasound. So they actually bring a portable ultrasound machine. And then they gather this data and liaise with the

family doctor. They work in a team along with nurses, nurse practitioners, pharmacists, OT, PT, you know, physiotherapy, occupational therapy, et cetera. And it's this team-based model that provides the care that they need. And it's something that can be scaled up across the country. And I can tell you that people in other countries have been looking very closely at what's going on in Renfrew as a model. I'm Steph. I'm an advanced care paramedic, a community care paramedic with the County of Renfrew. We normally see people who have, I'd say, three, four more chronic conditions. So anywhere from breathing issues to heart issues.

So in the summertime, we get a lot of people who have breathing issues end up having COPD. So those are two ideas that are based in Canada, or two pilot programs in Canada. The one program from another country that I really think is worth looking at, it's something called Budzorg. It's from the Netherlands. It's the word Budzorg is Dutch for neighborhood care, and it's a different model for providing home care. So in that country, in the Budzorg model, instead of having a centralized agency dictate what each client will need for home care, and this is how many hours you get, whether you need more or not, this is all you're going to get. Instead, you have self-governing teams on the front lines consisting of 10 to 12 nurses providing medical and supportive home care services. And they receive a budget. They can spend it as they see fit based on evidence.

And their job, their task is to look after a neighborhood consisting of 10,000 people, of which at any one time, typically 40 require home care services. And they have the leeway to spend more on a client if they need more and take that money out of what they'd be spending on the other clients. You know, obviously they have to spend the money wisely. There's a big emphasis on prevention and a big emphasis on sharing best practices. And this is something that we could adopt in Canada quite easily. Right.

Well, I mean, it just occurs to me that all of the models that you're talking about there, you know, all three of them seem like they firstly give like more personalized care to the patients, but also take pressure off of these kind of blockage points in the system, like putting too much pressure on ERs, not having enough family doctors in a region. All of these things kind of alleviate the pressure on those areas where there are those bigger blockages. Absolutely. I mean, what about bigger, broader, more substantial changes? Like, how does the whole system in Canada, in your opinion, need to fundamentally change? Well, there's lots of ways.

The most important thing we need is long-term planning. And I don't know who provides that. I think when you have planning based on election cycles of three, four years, two, three, five years, it doesn't work. You don't get that long-term planning. We need to be planning now for the healthcare needs of our population, not just in five years, but in 10, 15, 20 years. So overall planning, taking a really hard look at health human resources, like who do we need? What skills do they need to have? And how do we train the next generation to provide them and pay them in a way that will make it attractive for them to want to do it. I think investing in a team-based model is really, really important because the individuals are less likely to burn out if they work in a team-based model. So that's another thing. I think we need another general principle is accountability. We need to

reward innovators. We need to reward people who put in extra time, not just for the time they put in, but because they get better results. We need to reward better results. We need to, frankly, penalize results that are less than what we think the standard should be providing. know, than what we think the standard should be providing. You know, I think we need a cradle to grave single electronic health record that is recognized across the country and is portable. You know, and then you can start thinking about some of the, you know, we need to invest in more training at the university and college level. There are things that we can do to make things better.

You know, our acute care needs, Our acute care needs for the healthcare system involve ways of increasing retention of healthcare workers and redistributing them. I know that the Canadian Medical Association's talked about a national licensure to allow greater portability for doctors and nurses and other healthcare providers. I think that's a short-term thing, but the longer-term fixes are just as important. They may not seem as urgent, but they are. So, I mean, among all of these, you know these possible fixes that you're talking about, is there a sense from either the federal government or any of the provincial governments that there is any kind of plan to actually address any of these major issues? I have my doubts because, you know, health care is regarded as a provincial responsibility and, you know, the federal government, not the federal government, but any federal government that dabbles for the federal government to take a paramount role in health care across the country could be a recipe for more centralized control, which may not work. that as long as health care is key to the election cycle,

I think that you're going to have these short-term considerations kind of outweigh the long-term thinking that I've been talking about, and not just me, that people a lot smarter than I have been talking about is very important for putting health care in this country on a better footing. Well, whether or not it's political leadership that will save the health care system. I mean, how do you think regular Canadians who, you know, really care about the public health care system can help strengthen it now? Well, I think they have to tell their elected members of the legislature, parliament, that they want publicly funded health care, that they want it to work. They don't want it to collapse. Part of that means that if we have to pay higher taxes, then we have to pay higher taxes. But it's a choice that Canadians have to make. You're not

going to get this for free. You will go a long way by redistributing, you know, how we spend money, spending it more wisely. There's no question about that. But it will cost more than we're spending now and will probably continue to cost more in the years to come. Brian, thank you very much for this very important conversation. I really appreciated it. You're welcome. You're welcome. All right, that's all for today. I'm Allie Janes, in for Jamie Poisson. Thanks for listening to cbc.ca slash podcasts.