In January, I wrote a brief introductory essay on the reasons I feel patients must be included as full partners in health care, having not just the right to good care, but also responsibility for certain facets of the health care system. There were so many comments and concerns raised by that introduction that I felt it was important to follow up with a bit more information to think about and clarification of why, in my view, patients need to be full partners in accountability.
One of the striking facts about the Canadian provincial health plans is that government documents and websites highlight patients’ rights and never mention patients’ responsibilities. I looked through the documents for each province and territory. Here are links from the British Columbia website and an Ontario government website for new immigrants as examples. I attempted to find a document for Ontario similar to the British Columbia Document, but this did not seem to exist, except for new Canadians. The document for new Canadians does list responsibilities but I was struck by the fact that the website also contains this phrase: “You are entitled to all of the patient rights that are described in Ontario laws, even if you do not follow these “responsibilities.” The other document I have included is a Government of Canada comparative overview of patients’ bills of rights from around the world. Note once again that rights are noted without mentioning responsibilities.
Contrast this with the fact that other countries with a publicly funded system do list both patients’ rights and responsibilities. This is also true of many physician practice groups in Canada and hospitals. Both hospitals and physicians’ practices absorb the costs in their budgets if time or resources are not productive. In my hospital’s Youth Psychiatry program, missed appointments or late arrivals mean delays for another patient’s assessment or treatment. That’s why we have a rule that, if a patient misses more than two appointments without 24 hours’ notice, we close the file. Given that Ontario’s healthcare budget covers the cost of the therapy provided in the Youth Program, most patients and their families understand that missed appointments affect access to care and accept the rule.
The emphasis of patients’ rights, in the absence of a consideration of any responsibilities, makes physicians uneasy. It also makes many physicians, including me, feel as though the responsibility for stewardship of the system is not shared by patients.
All physicians have days when we feel as though every appointment consists of reviewing with patients that the tests they want are unnecessary and treatments they would like are proven to be ineffective. Physicians honestly want to follow best practices, and improve system efficiencies and these discussions with patients about necessity prove that. Physicians could have much less conflict in our days if we just agreed to order every blood test, consultation or x-ray that patients request. At the same time, every physician I know is very understanding when a person’s living conditions or financial situation make it impossible for them to follow the recommendations they’ve received for examinations or treatment.
One reader of my last Patient Accountability essay commented that defining patients’ responsibilities was a “slippery slope” to blaming patients for their health problems. My experience is that anything less than a full discussion of a patient’s history, examination and diagnosis, along with an outline of the best practices for further tests and treatment is a “slippery slope” to an old style of medicine in which the patient was expected to “do what the doctor ordered”. That kind of paternalism is no longer acceptable in medical practice. The standard of care today is to review the diagnosis and recommended tests and treatments thoroughly so that patients understand the options for further evaluation and treatment and consider with their doctor and other care providers what would best for them. Patients no longer want to be patronized by the doctors providing their care.
Canadians are aware that their much-celebrated health care system is not keeping up with demand and it would be a relief for most people to know that there was something they could do to preserve and improve their health care. We are all aware that many Canadians can no longer afford necessary medications, but we also realize as our national and provincial deficits increase that we cannot spend away the health care system. Providing good care in the context of excellent information about best practices is what all doctors try to do. My experience with patients is that they want this information so that they can do whatever it takes to get well. How is that not taking responsibility? Why can governments in Canada not accept that this is the right thing to do?