Comparison Shopping for your Health Care System Part 1

In the end you are still taking care of the patient

Since I have been in practice in Canada for six months I thought it might be time to reflect on the similarities and the difference s between the US and Canadian system of health care. As a reminder, I am a Family Physician. This means that I take care of whomever walks through my office door to the best of my abilities regardless of age, sex, or ability to pay. I see everything, and refer to specialists when I am out of my comfort zone, or have run out of good ideas. So a good place to begin our review would be in the typical clinic day.

The View From Texas

When I practiced in Killeen for Scott and White my day started in clinic around 8:30. I would see a patient basically every 15 minutes until 12pm, break for lunch, and start at 1pm and continue until 3:45pm. This resulted in seeing about 26 patients a day give or take (depending on how many physicals I had that day).

I usually arrived earlier in the morning to try and answer all the patient messages, look over lab results, complete forms, and answer e-mail prior to the first patient of the day. I dictated my charts as I went and that usually took 2-3 minutes per patient so I spent roughly 10-12 minutes of each visit with the patients. During that time you would try to complete all the work that needed to be done for this patient. The presence of the electronic medical record allowed me to review all the visits since the last time I had seen them as well as all the specialty visits. It also let me look and see if they were up to date on their labs, preventative care, and such. Some days the computers worked well and this did not take much time, other days they were slow and it became difficult. In general, my patients were older with my average patient being late 60s early 70s with the occasional child thrown in for variety. If a patient needed a procedure done often it happened during their visits, or was quickly scheduled for my dedicated procedure day.

The days felt very busy and I usually returned home feeling fairly worn down. I usually left the clinic in Killeen after 4:30 or 5 pm and then headed to the house. As part of my practice in Texas I did the occasional delivery usually in the wee hours of the night, and one week of every six was spent working in the hospital taking care of the hospital service. On the whole, the patients that I took care of in clinic and in the hospital were older sicker folks.

The View From Prince Edward Island

My practice in Canada is usually starts around 7 am with hospital rounds at the Alberton hospital where I see my one or two patients, then I drive to O’Leary for hospital rounds on my one or two patients. I arrive at the clinic between 8:30 and 9 am to begin my clinic day. I see a patient every 15 minutes from 9 am through 11:45 and then from 1 pm until 3:45 pm give or take I see between 23 and 25 patients a day depending on the number of work-in patients.

During the visit you work on many of the same issues as I did in Texas, catching up on preventative health care, reviewing labs and such to monitor chronic illnesses, and cajoling patients into changing their lifestyles. Since the notes are handwritten, there is no time spent dictating the chart (and thus no time spent signing off on dictation). Since it is a paper chart, there is a bit of work to keep the flow-sheet organized so that you do not have to dig through the chart each time you want to review preventative care. Because of the manner in which the clinic is arranged, it is difficult to perform procedures in the clinic, so I often send those to myself when I am going to be working the urgent care clinic. You still have the usual lab to sign off on, as well as the consults to review and such, but the paperwork that seemed to be such a large part of my practice in Killeen is not here. I do not have any pre-approval insurance forms to complete, and I cannot think of the last time that I had to complete a Pharmacy Assistant form for anyone. The patients do not seem as ill either. I have some terribly sick patients (i.e. the renal failure alcoholics with diabetes) but they are not as big a part of my practice as they were in Texas. The pharmacy does not fax forms to me for refills, they either refill the medications for one month and have the patient make an appointment to be seen, or they call me directly during the day and I give them the go ahead. This relieves all the pharmacy paperwork that I had from Texas and it was a huge chunk of my paperwork.

There are some distinct differences in the prevalence of certain medical conditions, specifically thyroid disorder, crohn’s disease, celiac disease, and cancer, but I think that these represent the effect of a small isolated population (after all there was no direct connection to the mainland until 20 years ago). I usually complete all my work by 4:30 or 5 pm and head home. I am no longer delivering babies so I do not have those night-time calls. There are two duties that I did not have in Texas that are part of my practice, the Urgent Care Clinic and the Emergency Room. On average I have one call in each location weekly. Usually they are back to back where I work the UCC one day and the ER the next. The hours for the UCC are from 8 am to 8 pm and the volume is variable. The ER is a 24 hour shift, and volume is steady but manageable. As influenza has arrived in our part of the island, the UCC and ER have become very busy places. Despite the addition of daily hospital work and the shifts in the ER and UCC I do not feel as tired as I did when I was in Texas.

Quelle est la différence?
The question in my mind is why am I less fatigued than when I was in Texas. I have been giving this a great deal of thought over the last weeks and I have come to a couple of conclusions.

First, the ever present push in Texas to see more folks all the time felt like a weight on you back. The addition of 3 patients a day meant an additional 15 people a week really seemed to increase the work load (especially when you translate that into the additional dictations, labs, and pharmacy faxes).. Where I feel like I have the time to talk to folks here, I never really felt that previously.

Second, the patients have a different level of expectation in Canada. In the US I always had the feeling that patients wanted everything done all the time whether they needed it or not. I felt like I was always counseling patients about why they did not need antibiotics, an MRI, or a CT scan. The sense of entitlement that I felt form the patients in the US was always present as was a continuing concern that someone was going to file suit for the care that you provided. I am not saying these are rational feelings, but they reflect the feelings of the day when I was practicing. As well, my conversations with my colleagues during lunch confirmed that others felt the same way. The patients here do not demand that everything be done, and if you are sending them for extra tests, they do not fret if these tests take a couple of weeks to get accomplished. With the malpractice laws in Canada, the frequency of litigation is low, and patients do not seem to view it as a lottery like chance for a big win.

Finally, paperwork here is not nearly as onerous as it was back in the Texas. I know it goes against what I initially expected from a government run system, but the amount of paperwork that flows through the clinic is not nearly as copious. This burden was one I did not really appreciate until it went away, and I do not miss it one bit.

Well that is the first view of the similarities and differences. I will post more on this subject over the course of February and try to continue to fill in the gaps so you get a good feel for what is working and not working in both systems. Stay tuned.