The CMA's Dr Sunil Patel
knows how to fix the system

For starters get "multiple players" out
of the patient-doctor equation

IINTERVIEW BY M. HUGH COULTHART

Dr Sunil V Patel, President of the Canadian Medical Association (CMA), was born in India where his father was a physician. When he was eight years old the family moved to Uganda. In 1964, at 16, he was sent to boarding school in England and went on to the University of Sheffield where he received his Bachelor of Medicine and Bachelor of Surgery in 1972. He completed postgraduate training at the Health Sciences Centre and St. Boniface General Hospital in Winnipeg and, in 1973, set up a general practice in Gimli, Manitoba. He and his wife, Theresa, have three children.

NRM: You've practiced medicine in rural Manitoba for more than 30 years. That shows a certain commitment.
Dr Patel: A patient once asked me quite candidly, "Why are you still practicing here in Gimli when you could be elsewhere doing much more interesting things?" I said, "Well, it's interesting. I haven't sat down to think about it, but now that you ask, it has to be my patients. They are my family." I would say by and large that physicians who continue to practice in Canada Ð and I would hazard to guess that it would be in the 80-90% range -- do so because they are dedicated to their patients. It would apply to nurses as well. It's a calling, in addition to a profession.

NRM: Yet you feel the practice of medicine in Canada has deteriorated over time. Why is that?
Dr Patel: I've grappled with that. There are a number of factors, but there has to be some underlying reason, and I believe that reason is that there is a third-party payer who is now the Pied Piper, so to speak. You lose that relationship between your patient and yourself, that degree of fiscal responsibility on the part of the patient, and on your part an accountability to the individual patient.

NRM: To whom have the physician and his patient lost that relationship?
Dr Patel: Well, to Medicare. Medicare is an amorphous government agency.

NRM: Focusing on the general practitioner, might the role of the physician be redefined to improve the functioning of the healthcare system from both the patient's and the doctor's point of view? I'm thinking about the role of the GP/FP as the patient's advocate within the highly complex healthcare system.
Dr Patel: It's interesting you should ask that, because that's exactly been my impression in 30 years of practice. This fragmentation of patient care, I believe, has led to two things, that certain loss of glitter to the doctor-patient relationship, and the fact that when you have multiple players involved, all operating in silos, you get duplication, increased costs and undue apprehension on the part of the patient.

In an ideal world, if I as a general practitioner were allowed to re-engineer the system, I would say, "Thank you, Mr Specialist or Psychiatrist, thank you for your opinion! Now that you have confirmed my diagnosis, tell me what are the pitfalls, what I should look for, and tell me when I should ask for your assistance again," instead of having two people looking at that patient simultaneously. Then the patient gets ambivalent about who's right and who's wrong, and it creates a sense of fragmentation that's not healthy for patient-focused care.

The fragmentation of patient care has led to two things, a certain loss of glitter in the doctor-patient relationship, and increased costs and undue apprehension on the part of the patient.

Even though we say that we should be a collaborative model of care, there are two impediments to that collaborative model: governments have tinkered with the system for the last 30 years purely on a fiscal basis, trying to save money -- and let me tell you that they have ended up spending more money -- and number two is that they have not provided the tools or the milieu in which collaboration can occur. They have not engaged the healthcare professionals. The physicians have not been at the table in a meaningful way.

And there's mistrust between them -- I call "them" the Medicare system, governments, regional authorities -- and us, meaning the providers, the end-users. "You will design the system to benefit yourself, to line your pockets," they charge. Well, excuse me, but if that was my intention, I would have left this country a long time ago.

NRM: Is money the main reason Canadian doctors relocate to the US?
Dr Patel: I don't think so. [I attribute] Canada's continuing loss of talented medical professionals to a breakdown in collaborative relationships within Canada's healthcare system, between the patient and the doctor, the patient and hospital nurses, and the general practitioner and the specialist. These fracture lines are the root cause of the delays in the delivery of healthcare to patients. This is the greatest frustration, not just for patients but for physicians and healthcare workers as well. Repairing these fracture lines and reducing delays are urgent requirements.

NRM: That seems a simple notion yet the healthcare system is notoriously resistant to change. What time frame do you see for these changes?
Dr Patel: What we need to do is to fix the gaps immediately. If you address waiting lists, if you address human resource crises, if you address the number of spots for students and postgraduate residents and IMGs (international medical graduates) in the system for training, I think within 10 years you could see a tremendous difference in healthcare delivery in Canada. You don't need a fancy study to do that. And we're not talking about huge sums of money. We're talking about targeted spending in an expeditious manner.

NRM: Do you foresee the new National Health Council playing an effective role in making these kinds of positive changes?
Dr Patel: If the National Health Council buys into this concept of three or four areas where we need to target specific investments immediately, then we can continue to monitor the effect of that targeted spending. Second, it needs to report progress to Canadians. And the Council will only be effective if it's independent, not subject to political arm-twisting. After all, it's a government-appointed chair, you have government-appointed representatives, even the non-government representatives have been appointed by government. So it's already loaded to begin with. That's not to say that we do not approve of the Council, but the Council's work can only be judged based on it's independence. If they truly believe in Canada and our Medicare and put their political affiliations aside, then we will have a better healthcare system.

NRM: Are you optimistic?
Dr Patel: I'm an eternal optimist; having said that, I am cautiously optimistic, but not in a way that I would like to be. I think the only way I could be made optimistic would be to engage the physicians of Canada, the CMA and other healthcare providers in a unified approach to the redesign and reshaping of the system for better care in Canada. Then I'll be optimistic. Until then I tend to have a guarded, healthy sense of scepticism. In fact the reason I left the UK was because I saw the danger signs in the UK's National Health Service in 1970. Unfortunately those danger signs have caught up with us in Canada. Having committed myself to my patients here, it's very hard to extricate myself and go to greener pastures. I hope to use my CMA presidency to reshape the environment and to help improve the system so that future generations of physicians, nurses and patients can benefit.