It seems like every week there’s a new dispute over health-care spending. Hospitals, governments, nurses, doctors, political parties, multinationals and entrepreneurs are all fighting over who should get paid, how much and for what. Most recently, the Ontario Medical Association launched a constitutional challenge to Ontario’s clawback of doctors’ pay. At the risk of falling out of step with my colleagues, my hospital and my government, I think everyone is missing the point.
I’ve been a psychiatrist for people with physical diseases for more than 20 years and I work in a hospital. I’ll translate the highlights from a typical week into dollars, since this seems to be the language that matters now.
I see J, a young man who needs treatment for a viral infection that is the direct result of addiction that came about because he was trying to calm the terror caused by a childhood of beatings and emotional abuse. There is no reason J should have been sick at all, but his treatment will cost someone $80,000 or more in the next six months. Also, his life is a chaos, but I don’t know where to put that in the tally.
The next day I cover the geriatric psychiatry service for a colleague who is away. The team is trying to figure out how to prevent K, a man with Alzheimer’s disease who thinks his roommate is stealing his stuff, from scaring L, the roommate who thinks K is trying to kill him. This costs quite a bit of money as well. I am well paid for my time. The nurses who are trying to sort this out and are much more effective at it than me earn less, but there are four of them so it adds up. K and L are both occupying acute care hospital beds that they don’t need (ka-ching) because there is nowhere else for them to go. I don’t know who would be in those beds if they were available, but whoever they may be, they are living in the hallway of the emergency department right now. Very expensive.
Back in my office I see a woman, M, who has chronic pain and depression, labels which do not begin to describe the roller-coaster of emotions and suffering that she experiences. The pain is caused by complications of being raped when she was a child. Multiple hospitalizations and surgery have not helped. Social programs and community resources that can reduce family violence are expensive but hospital stays and operations cost a lot too and seem a poor substitute. Foster care did nothing to help M figure out how to manage those feelings, but finding a caring partner, a social worker and a good family doctor have made a world of difference (the latter two are relatively cheap).
And so it goes, week after week, because these are common problems. One out of every four children experiences abuse or neglect. That statistic is either appalling or kind of boring depending on your perspective. The stories are simply appalling. The prevalence of addictions and mental illness are even higher.
Treating seniors who need considerate care and palliation with tools that were developed to diagnose and treat acute diseases is both expensive and nutty. And yet this is what we do. Seventy per cent of Canadians receive their end-of-life care from hospitals and 10-15 per cent are treated in the intensive care unit during their final hospital stay.
Everyone agrees that the current system does not meet many patients’ needs and is unsustainable. I wish I had more confidence that money that is redirected from doctors and hospitals was going to help the next J, K, L or M. More selfishly, I don’t want to die in the ICU. If dementia makes it too difficult or unsafe for my family to care for me, I don’t want my new home to be an understaffed general hospital.
We have to do better. We need effective resources in our communities to promote prevention and provide end-of-life care. But to get there we need to stop fighting, listen to each other and remember who we’re trying to help. I don’t know how to put a price on that.
– Dr. Robert Maunder practices at Mount Sinai Hospital. He and Dr. Jonathan Hunter are the authors of Love, Fear, and Health: How Our Attachments to Others Shape Health and Health Care (University of Toronto Press, 2015)