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.

Uh…Hello….its Canada………. (spoken in a valley girl voice)

Well Nancy has finally arrived in Canada.

What? I thought she came with you?

She wrote about Halifax, how can she have just arrived?

We all have moments in life when a realization hits us smack in the forehead, a Satori moment if you will, that moment of utmost clarity when you seem to see the world around you in a very different light. Sometimes those moments are the end of a long quest of the most profound nature, at other times they arise from the simple act of looking at your shoes in a different light. Either way, they offer you the opportunity to shift your viewpoint of the world, to allow you to see the world anew. It is a moment when you look out into the world and see everything around you as if you are seeing it for the first time.

Well, Nancy reached her Canadian Satori this week in the Atlantic Superstore. She was in the store shopping for groceries for the week, and headed to the Deli counter for some sliced turkey. After carefully pursuing the options available and considering the particular taste preferences for us both, she determined that the sun roasted tomato and rosemary turkey would be the best option for the week. Decision made, she promptly moved on to the instructions for slice width and quantity. As usual she wanted it sliced as thin as possible without shaving it, and as always she asked for one half pound. She promptly moved on to thinking other thoughts and waiting on the delivery of the turkey. She snapped back to reality when she noticed the large pile of turkey that was accumulating.

Nancy: Whoa, whoa, whoa…..what are you doing?

Deli Girl: weighing the turkey.

Nancy: Yes but I asked for a half pound, and that's way to much

Deli Girl: Yeah, but I don't know what a half a pound is, I usually pile it up until I think it is enough and ask the customer if it looks good.

Nancy was enlightened, she was in Canada, the measure in Kilograms, and she had no idea how to convert from pounds to kilograms. Her world had changed. She was different and the world around her would never be the same.

We hope that you are all doing well, and that you all have a moment of Satori in your lives. We shall post our Christmas Letter in the next day for everyone.

What is he saying (Part II)???

Whenever you go to a new location you can expect that things are going to be different (see part I of what is he saying???). For instance, when you go to France you expect that things will be in French. Likewise, in China you expect Chinese, Korea , well Korean of course. So when you arrive in Canada you should expect to hear some Canadian.

Wait, I thought the Canadians spoke English and French?
You are in fact correct.
Then what is Canadian?
That is the version of English they speak.

Today I pay tribute to some noteworthy differences that I have picked up over the last month and a half. Some are in the way in which folks pronounce things, others in the adjectives and adverbs used to highlight the conversation. So, let’s go through my most recent examples of differences from our common language.

The first example comes from Nancy and her interaction with a car salesman. We have recently purchased a happy yellow Chevrolet Aveo and we enjoy it when it runs (and when it does not it goes back to the salesman to have it looked at and fixed….a completely separate post). It was during one of her visits to the dealer to pick up the car (again) that they got to talking about the color. She calls it happy yellow. This led to a conversation as follows (deckle rhymes with freckle).

Salesman: You ought to get a deckle for that car
Nancy: A what?
Salesman: A deckle of a nice yellow smiley face, there is a guy down the road who makes em, eh.
Nancy: Confused look on her face
Salesman: See he made all those deckles for my other cars, eh.
Nancy: Light bulb comes on and she realizes he
means Decal. Hmmm………

The second example comes from several patients I have heard over the last week. You see we have had a bit of stomach flu in our community (a gift from the return of the school year). So I have seen several people with the same basic complaints.

Doc: Hello Mr Whomever, what is going on today that brings you in?
Patient: I been sqwamish, terrible sqawmish.
Doc: I see (Puzzeled look on my face masking as concern)….Tell me a bit more about it.
Patient: I been wake up terrible sqwamish, can’t hear tell of eating, make me terrible sqwamish.
Doc: Have you been throwing up?
Patient: Only when the sqwamish gets terrible.

After several encounters I began to understand that sqwamish meant squeamish. It is an unusual way to describe nausea, but I guess it works. It certainly gets the point across once you understand what they are saying.

The last bit comes from differences in the way we describe the same things (taken from the medical setting).

Terrible = As an adjective such as a Terrible smart, Terrible big, Terrible pretty, Terrible sick, or Terrible tasty. In some parts of the country they would substitute the word wicked. In Texas you might hear the word powerful in place of terrible.

Getting a Needle = an injection of some kind
Freeze it up = Numb an area for something like a stitch or an excision
Prick, as in “ I had to prick her three times to get that IV started”. I am used to hearing the word stick in place of prick.

I will continue to listen for more curisities form the north.

Well for all of you that are sweating away in Texas, you will wish that you were here. The weather is glorious, and the fall colors are beyond anything I have seen . The leaves have an electric almost fluorescent color to them as they turn brilliant yellow, red and purple. Here is a link to the science behind the changing of the leaves. I only hope that Kyle does not blow them all away prior to getting some photos of them for everyone. For now head over the flickr site (click on the slideshow on the right) to see some new photos we posted form a trip last month to the north shore of the island.

When do you serve lunch?

For anyone who has travelled around the United States, it is not uncommon to have the mid-day meal referred to by a variety of different names. Most folks in the southern states refer to the midday meal as either lunch or dinner. What is the difference?


Well both meals occur at the noon hour, so how could you tell one from the other?

I have always been a bit confused about this difference in terminology and so I went to that bastion of knowledge, the Merriam Webster dictionary (on line version).

Lunch
Etymology: probably short for luncheon
Date: 1812
1: a
usually light meal ; especially : one taken in the middle of the day

Dinner
Etymology: Middle English diner, from Anglo-French disner,
diner meal, from disner to dine
Date: 13th century
1 a: the principal
meal of the day b: a formal feast or banquet

Supper
Etymology:
Middle English soper, from Anglo-French super, from super to
sup

Date: 13th century
1 a: the evening
meal especially when dinner is taken at midday b: a social affair featuring a
supper ; especially : an evening social especially for raising funds
2:
the food served as a supper 3: a light meal served late in the evening

Well that seems to clear things up nicely now doesn’t it.

So if you drop by the clinic and catch me in the middle of the day eating a sandwich at my desk, then you have stopped by for lunch. However, if you find me at home on the weekend and we are having grilled chicken and oven vegetables then it is likely that you have come for dinner. Clearly when you come by in the evening we are having supper no matter the form or content of the meal.

This all seems perfectly clear until I went to the local Masonic lodge meeting. Lodge get’s started at 8 pm, and afterward they have a small light meal. During the meeting we talked about an upcoming event that was to take place in the evening in two weeks. We were going to have a speaker and everyone was talking about the timing of the lunch break. I must admit I was confused about the timing of the events. It was clear to me I had misunderstood when things were going to be taking place, and I was a bit sad since I clearly could attend since it would take place around lunch. It was all very confusing to me since everyone was clearly referring to an evening meeting (the lodge will open at 7:30 pm and the speaker will start at 8:15 and we will break for lunch at 8:45).

My confusion deepened when at the end of the lodge meeting they asked me to stay for some lunch. Understand the time was 9:30 pm, and I had already had supper with Nancy earlier that day, and lunch had consisted of a sandwich and some havarti cheese in the clinic around noontime. I stayed because my curiosity was high, and in very short order small sandwiches appeared as did small cookies and cakes and everyone sat down and had a social gathering over this meal with tea and coffee.

As I left that night, I figured that this was just one of the crazy local things. They referred to the morning meal as breakfast, everyone seemed to refer to the midday meal as dinner, and the evening as supper. This makes obvious the idea that the cafeteria served a hot dinner at noon (i.e. something freshly cooked and warm such as seven layer dinner), and a cold supper at 5 pm(i.e. soup, salad, wraps and such). Lunch must be when you have sandwiches. However, I have come to find out from very reliable sources that lunch has no real time and instead refers to the meal that occurs after an evening of socialization.

It does not refer to a light meal as Mr Webster implies, rather on the island it refers to the meal that happens after supper. These meals may be simple such as that of the lodge, or they may be very elaborate happenings. In fact, in the winter when folks seem to socialize more (since the weather does not permit much outside activity) people will gather for cards or some other function. Often a lunch will follow before everyone goes home. When the group convenes next, the hostess will serve something completely different, and often a bit more elaborate than the previous week. By the end of winter these lunches can take on the scope of a rather grand buffet and everyone is leaving the party feeling very full and very happy.

So there you have it, the fourth meal of the day, the meal before bedtime, or the meal when at work. Lunch it is more interesting than you could possibly imagine. Learn more about lunch, supper, and dinner at Wikipedia. You can also see the entire meal series at Wikipedia.

What is he saying????

Well I have officially completed the first 36 hours of gainful employment for the Beechwood Community Clinic. As luck would have it, I began my time as a Canadian doctor in the Emergency Room. It was not too bad, a pretty forgiving 24 hours all things considered. The role of the emergency room in Canada is very much the same as it is in the United States in that it serves as the catch all for anyone who does not have a personal family physician (called orphans in Canada) or those who cannot get in to see their personal physician. The patient complaints were not all that dissimilar to those seen in any urgent care setting: coughs, colds, gastrointestinal problems, as well as the odd trauma. In addition to these general difficulties you also see the expected cardiac difficulties etc that come along with an Emergency Room.

The two biggest differences that I noted were the social admissions and the difficulty with language. Let’s begin with the social admissions. Since the health system is socialized, this includes the nursing homes. So, when a patient comes to the hospital and needs to go to a nursing home and the nursing homes are full, then they stay in the hospital until there is a bed available. It is probably not the best use of resources, but it does fulfill the needs of the patients and upholds the social contract. It will be interesting to watch this over the next several years.
The second difference that I noted was the difficulty I had with the dialect as well as the colloquialisms. The dialect was very interesting for me and on a couple of occasions I had to grab one of the nurses to help me decipher what the patient was trying to say. It was especially difficult for me as the evening wore on, and my fatigue increased. Add to this the use of different phrases to explain things and it made for a very interesting evening. My favorite saying form the evening was from a patient in response to the question describe your pain…..’it’s like water running down my legs’. Now I have no idea what that means, but it is certainly descriptive. I am just glad the response was not along the lines of ‘ the way water smells when you make butter’. The nurse translator was not very helpful in figuring this phrase out, and so we had to come at the question form several different angles.

My first day in clinic was very enjoyable as well, and it was much like any other clinic in many respects. What made it more enjoyable was the small town feeling of the clinic. It is a familiar feeling for me, and reminds me very much of my time as Dugway Army Proving Ground. One of the best treats of the day was the presence of a coffee break that happened around 10:30 am. Since there is no scheduled time for tea or coffee, one of the nursing staff brews a pot of coffee and steeps a pot of tea and brings all of it to the doctor’s work station for everyone to enjoy. It was a very pleasant treat in the middle of the morning.

All in all it was a very enjoyable start to my Canadian medical system. In the next several days we will talk about the other big differences and the challenges that I can see myself facing as time progresses. In short, standard international units (http://jama.ama-assn.org/misc/auinst_si.dtl) in place of conventional units as well as different medications. More to come.