Train up, go nuts, and opt out?

Doctors in some provinces can bow out of Medicare,
but is going it alone really all it's cracked up to be?

BY GIANCARLO LA GIORGIA

Two years ago, GP Dr Chantal Ducasse's frustrations with Quebec's public healthcare system brought her to a crossroads in her career--she was either going to open her own private clinic, where she would be the boss, or quit medicine altogether to play golf full-time.

"I was seeing 50 patients in six hours and I was tired of it.... In a practice, when you see so many patients at a time you can make misdiagnoses so easily," she says from her Multi-Medic sports clinic on Nun's Island, just south of Montreal.

Dr Ducasse says her breaking point occurred one day while working at a walk-in emergency clinic in Montreal's South Shore. She was examining a patient who was complaining of shoulder pain. As the only doctor on duty, with one secretary and a waiting room overflowing with patients, she says the pressure was to just send him home with a prescription for anti-inflammatory pills and move on to the next patient. However, her instincts told her to administer an EKG test, which is when she discovered that the patient had suffered an acute heart attack. She decided that from then on she wanted to work independently of the public system: "I didn't want to practice that kind of medicine; I wanted to take my time so I wouldn't make mistakes. I was lucky that time."

Though stories like this may be commonplace, Dr Ducasse's reaction is not.

According to Health Canada, there are less than 100 out of about 55,000 Canadian doctors, mostly cosmetic surgeons, who are designated as non-participating or de-enrolled from the public healthcare system. This means that their patients are billed directly, according to a set schedule of fees, without any reimbursement from Medicare.

In 2000, an assessment of universal healthcare by the CMA cited insufficient funding as the source of the "unconscionable" delays in the diagnosis and treatment of diseases such as cancer and heart disease, and this August the CMA passed a resolution urging the federal government to put Canadian healthcare back at the top of the world within the next five years. However, for doctors like Ducasse, tired of toothless reports and commissions, opting-out of Medicare is the only way to cut through the bureaucratic red tape that has increasingly whittled away four of the Canada Health Act's five pillars--comprehensiveness, portability, accessibility and universality--and broadened the one pillar of public administration.

Dr Ducasse, who specializes in sports medicine, has worked with the Canadian short-track speed skating and National Women's Hockey teams. She was the first non-participating female doctor in Quebec, where the majority of Canada's private practitioners--22 GPs and 40 specialists--work.

Her clinic is situated in a well-heeled enclave where several of the city's pro athletes live, but she maintains that her clientele is divided mostly between

casual sports players, assorted professionals and "Mr and Mrs Everybody." She personally designed the clinic, from the logo down to installing its hardwood floors. Since it opened in May 2002, she's done her own publicity and marketing, worked 100-hour weeks and seen her earnings drop by 35%. Nevertheless, Dr Ducasse says she prefers "monetary insecurity over the security of the public system.... I like being free as a bird and not having the government tell me thing like ÈYou will go work in Sept-Ùles tomorrow because we need a doctor there.' I find that we're the only profession that can't decide our own destiny."

Though she insists that she's never been happier with her practice, she hints at the difficulties of entrepreneurial medicine, where there is no guaranteed flow of patients because "as a private doctor, if you're not good, if you're not kind and human with the patients, you won't have any."

In her opinion, doctors in Quebec aren't paid to spend the time to thoroughly investigate a patient's condition. In Quebec, she says, "you make a decent living when you have a walk-in clinic and see eight or 10 patients an hour." She laments the growing trend of referring patients to a specialist, where the waiting list can be months long.

"Family doctors are not well rewarded when doing traditional family medicine; they're much more rewarded if they treat sinus infections or the flu."

Dr Ducasse disputes the often-cited notion that Private-Public Partnership(P3) will provide quality healthcare only to those who can afford it. "When critics say that private healthcare is out-of-reach financially to most people, and that private doctors discriminate against the poor, I don't agree. If a person can afford $60 for a carton of cigarettes or $50 to get their hair done at the salon, why is $60 for a general check-up so outrageous? It's perverse. The fact that healthcare is free encourages people to consume healthcare services with abandon. That's what's expensive."

Though she is one of only a few Canadian doctors whose vision of medicine doesn't fit with those of Tommy Douglas, the former Saskatchewan Premier considered the father of universal healthcare in Canada, she encourages all doctors to work together to create something better for themselves and for their patients. "It makes sense--when you feel good as a doctor, the patient will sense it and you'll both be happy. I don't condemn public doctors, on the contrary I think they have more courage than I do to continue working in the current system."