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.

Merry Christmas From PEI

It’s Christmas Eve, Irving Berlin’s White Christmas is on the TV, snow is gently falling outside (making our own white Christmas), the furnace is piled high with logs, and I am putting the finishing touches on our yearly Christmas greeting. Our Christmas greetings come to you this year from the North Atlantic Island of lobster, potatoes, and ADL. ADL? ADL is the maker of the BEST milk, chocolate milk, butter, and cheese you can possibly imagine. Drinking a glass of their chocolate milk is like drinking a little slice of heaven (I just finished a glass!). Well, our greeting comes to you, as you know, from 83 Lewis Road, Union R.R. 1, Alberton, West Prince, Prince Edward Island, Canada.

We left the U.S. in August, leaving the dog days of summer in Central Texas (the day we left was 107 degrees with 100% humidity), and headed across the U.S. moving up the east coast. So, here we were, Gil and I, accompanied by 2 dogs, 1 cat, and 1 Lucy Bird, pulling our horse trailer filled with things we thought we would need until our household goods arrived, headed for Canada. Gil and I had never driven through the states lining the east coast so we were really looking forward to seeing the land. An added bonus, especially when traveling through the southern states, being in the land of really really good grits! Yummmm. The only part of the trip that truly sucked was going through Atlanta with a horse trailer, and we didn’t even go through at a rush hour time. Thank God Alli and Jesse gave us the wonderful gift of a GPS before leaving or the suck factor of Atlanta would have been significantly worse!

We stayed for a few days with Alli and Jesse in Swanzey, New Hampshire and the rest was greatly welcomed by us and the animals. We had a wonderful time with Alli and Jesse and got to spend some time watching Aaron, their 7 m/o son, being Aaron. He is a truly happy and delightful child. Even though this is their first and they have little parenting experience (7 months to be exact!), I told them they HAVE to be doing it right or he wouldn’t be so happy and well adjusted to life. He is a joy to be around. We had such a wonderful time seeing Keene (Swanzey is just a couple of blocks from there) and Walpole (where their family business is located). We brought sausage from Green’s Sausage House in Zabzkville with us and Gil made a huge pot of his gumbo. We had our usual trio of gumbo, baguette, and wine, accompanied by lots of wonderful conversation.

We crossed into Canada at the border crossing located in Houlton, Maine. We were prepared with a file box full of papers which were required to get us, the animals, and the car across the border and fully expected to spend hours going through papers and getting it all sorted. We were shocked and pleased that it was so quick and painless. Gil got his work visa and I got my Canadian papers and we were across the border in less than an hour (none of the documents we worked so long and hard to get in the U.S were asked for!). As we drove through New Brunswick headed to PEI, we looked at the scenery passing us in a different way than we looked at Canada all the times we had visited. This was our HOME now, and it makes you look at your surroundings quite differently.

The horses made it here about a week after we got here. There was a bit of difficulty getting them across the border. The transporter called me in a panic at midnight saying they weren’t going to let them across. We finally got everything worked out so the border agents understood why we were bringing them here and finally in the wee hours of the morning they made it across into Canada. When they made it to me they had a bit of a deer in the headlights look, but that is to be expected. They were on a transport from Texas to Maine for 3 full days without stopping, stayed over in Maine for 2 days, and then were on another transport for another 12 hours here.

Cowboy and Olivia have settled in and done well. I have been riding Cowboy and although it took him a bit of time to settle in and get back to where we were in Texas, he has been just awesome. In the past, when he traveled, a show was at the end, so he was in full (and I mean full with bigness and glory!) saddle seat mode. We finally got the dressage brain engaged again and he has been spectacular. I have been lunging and long lining Olivia since arriving, but haven’t ridden her yet. She has continued to be sound as can be and I have looked long and hard to find a driving trainer that I could continue lessons with and perhaps start Olivia driving. We attempted it once before with my trainer, Tom O’Carroll, in Texas, but she didn’t stay sound for it. Since then, we have had her on Naproxen, and she has stayed sound. The bad news is I can’t find a trainer. Most people on the island harness race which is, of course, not the same at all. I have, however, made a couple of friends who drive (not competitively) – carriage in the summer and sleigh in winter. So, I am going to get a bit of sleigh experience this winter. I am really excited about getting to sleigh this winter. The two horse experiences topping my list for PEI were riding on the beach and sleighing.


As most of you know, our Ophelia sustained a devastating injury on a back leg on Thanksgiving Day and the prognosis was extremely poor. It was felt by all that it would have caused her great suffering to attempt to fix it and in the end, we would have been putting off the inevitable. So, the decision was made and Gil was with her until the end. Of course, Ophelia was out of my mare, Olivia, and we were there at Dr. T’s when she was born. Alli took care of the farm while Gil and I spent every evening/night at Dr. T’s watching Olivia on the monitor, playing lots and lots of cards, until finally 3 weeks later, at 2 a.m., Ophelia was born. She would have been 3 years this January. This has been extremely difficult for both Gil and I, but especially Gil. He was bonded to her (and her to him); the way Olivia and I are bonded. It is so tragic and sad and we will miss her so much.

Gil started working on 01 September and is really enjoying small town medicine again. He sees patients at the clinic in O’Leary and also has some on-call time at the O’Leary Hospital. Of course, he has beat the “evidence-based medicine” drum since arriving and is now back to doing some teaching. He has just gotten a medical student who will be doing a one month rotation with him. Since he was a hospitalist at S&W the last 8 months or so before moving here, he wasn’t doing any teaching, so he is really enjoying having a student and teaching again.

There are lots of changes in medicine going on here though. For many reasons, they are consolidating services on the island and toward that end, they closed the ER and hospital (acute care beds) in Community Hospital O’Leary, where Gil works. Alberton’s hospital, which is 15 minutes from O’Leary (and closer to where we live), will serve as the local ER and in-patient hospital for acute care and when Gil is on call, he will work out of Alberton. All that sounds good, but we are not entirely convinced that Alberton’s ER/hospital will remain open either. It seems, what would make the most sense, is to have all ER and acute care in-patient in the 2 largest centers – Summerside and Charlottetown. Eventually the only services left in the small communities would be clinic/urgent care. These decisions and changes are very unpopular with the people of these communities, as all the individual communities want their own fully functional hospital/ER, so I imagine these changes are going to come piece-mill and slowly, but I think they are inevitable. So, this makes it difficult to know how to proceed with the horses.

Aside from helping a great deal with this kind of change, Gil is also doing here what he does everywhere he goes, seeing what needs to be changed to make patient care better and setting to work. Providence seems to have led him here for this reason, above all. There are many huge changes which are occurring here and change is something that is difficult for anyone, but it seems especially difficult for the good people of Prince County. The way they have done things in medicine for the past 50 years is being turned on its head and they are being catapulted into the 21st century of medical practice. In so many ways PEI is like the U.S. was in the 50’s and early 60’s and it is refreshing, but not in medicine. It will take probably a good 5 years to really implement these changes and have them running well. For all of you who really know Gil, that will be the time we will be ready to go on to our next adventure…

Willa and Isobel are very happy here. They love the snow, although it is s a little difficult to see Isobel dashing through it as it usually deeper than she is tall!! Lucy bird is great too. It is somewhat cold for her and we have to keep the house a bit warmer than we would otherwise and I keep an oil heater on next to her cage. She seems very happy there though. She is dangling off toys in her cage and talking smack constantly! We also brought Dory, one of our barn cats from the farm. She is now an inside cat, as she doesn’t care for the snow or the cold much!

Gil and I learned what it is to prepare for winter in a north Atlantic region. Everyone here utilizes two sources for heating – oil and wood. Oil is extremely expensive, so everyone uses it sparingly. So, we ordered our 7 cords of wood for the winter. Wood makes more of a warm/cozy heat than oil does as well. Our wood was dumped on the front lawn, 3.5 cords at a time, by the entrance to our basement and we had to get it down there and stack it. I won’t lie – it sucked. I am used to walking over to a thermostat and putting it to whatever temp I would like the house to be. Well, that really isn’t an option here. As our good fortune would have it, Alli and Jesse came for a visit for U.S. Thanksgiving and helped us with the second 3.5 cords. What a huge help that was. Gil had discovered on the first 3.5 cords that he isn’t 20 anymore!! After helping to get 7 cords down to the basement and stacked, I like the thermostat thing even more. Imagine this though – there are 70 and 80 year old men here who stack 7 cords by themselves every winter. Holy cow!

We really like it here though. The pace is MUCH slower here than in the U.S. I will say that has taken some getting used to. I tend to approach most everything with a snap, snap, snap, get it done now approach. You can forget that here. No one is in any hurry ever for anything. There is no such thing as running by someone’s house quickly to drop something off. If you go by, you have to come in for at least an hour for hot tea and conversation! Everyone here loves to talk. Even if you go into a store in search of something and have to ask for assistance, you will usually get at least 15 minutes of conversation before you get the answer. We went into a shop in Charlottetown which has woolen knitted clothing to look for a sweater for Gil – one sweater – we came out about 2 hours later! Even in the checkout line at the Farmer’s Co-op (grocery in O’Leary), a bit of conversation occurs within the check out timeframe (and if you don’t conclude it and move on, they will keep talking while folks just stand behind you and wait – and they will just stand there and wait patiently for however long and listen to your conversation!!) and it will almost always include comments about the weather. EVERYONE loves to make a comment on the weather conditions of the day. In fact, the other day I was sitting at the kitchen table working when I noticed the recycle garbage truck coming down our street and realized I hadn’t yet put out or recycle bags. So, I rushed to throw on warm clothing, grabbed the bags, and ran out to the street just in time. The garbage man, took my bags, threw them in the truck, and then proceeded to talk to me for the next 15 minutes about… the weather!!! He told me all about a horrible snow storm they got in the 1982 and how the snow was almost to the top of the telephone poles and how winters here have been really mild in comparison since… and on and on for 15 minutes. The garbage man even loves to talk! He was very pleasant and we had a very nice conversation.

I will have to say though that the folks we have become good friends with the quickest here are also people from “away”. That is was the locals call folks who move here and are not from the Island, even if you have moved from Nova Scotia. They say, oh you are from “away”! When folks say that to me, I say yep, we are from “way away”, 2400 miles, to be exact! Our good “from away” friends Pam and Jim, originally from Ontario, but have lived many, many places, are headed to Nunavut (above the 60th parallel) for the next year for Pam to work. It is only one year and they will be back, but we will miss them so much. We have had so many wonderful dinners with them and, in fact, that is where we will be on Christmas Day.

Being on PEI has been such a wonderful learning experience and we have only been here a short while. We know what it is like to stand in the midst of a blizzard, drive in one (the first snow of the season was pretty close to a blizzard and I had to drive home from the barn – 45 minutes away!), drive in a mixture of snow and then rain (slicker than poo you’d find in microbiology!) the smell of a woolen mill, the taste of exquisite ADL dairy products, the flavor of fresh (out of the ocean less than 2 hours, boiled in ocean water on the boat) lobster, and what it feels like to stack 7 cords of wood.

So, that about wraps up our year. It has been one of learning, joy, and sadness. We are still at the same e-mail addresses and you can always find what is new in our day-to-day lives by visiting Gil’s blog.

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.