With every doctor, pundit and reporter out in the media about doctors’ fees presently, I thought I would let them go at it and consider instead an item that I consider to be the “elephant in the room” of physician compensation negotiations everywhere in Canada.
Almost every physician in Canada that I know believes that our health care system would be much improved if patient accountability was expected of Canadians. Governments, however, have been opposed to introducing any patient responsibility despite the fact that there is significant evidence that there would be benefits for both the system and the patient. In fact, in conversations about how to manage the costs of the system, patient accountability is that subject which the government will never introduce, no matter how much doctors want to talk about it.
What surprises me about this is that many of my patients and their families are perfectly prepared to accept some degree of responsibility. What’s important about this is that my patients are mostly adolescents, a group that many believe are not at all prepared to be accountable for many of their actions.
A number of my patients, aged 16 to 18, come initially because a parent “forces” them to come. They will tell me they don’t want to be with me. I explain that I only want them to stay if they want to be there. Many will say, “Isn’t it wasting your time if I leave?” I can then point to a stack of paperwork on my desk and say, “I’d rather see you, but I have things I could do.”
Still, many are not convinced. It is absolutely clear that they have a sense that it would be wrong for them not to honour the appointment, even though they did not want it and usually did not make the appointment. That is the degree of responsibility that my young patients feel toward an appointment with a doctor for medical care.
You can also imagine that their parents feel the same way –I know it by the look on a parent’s face when I tell their son or daughter that I only want them to stay if they want to be there.
There are exceptions, of course, to this experience but the patient who wants to completely opt out of being in a responsible relationship with me is actually rare. Considering that supposedly irresponsible adolescents can accept responsibility for their mental health treatments, I am driven to ask: why can we not expect patient accountability at the system level?
What might this entail? In my clinic, it means that, first of all, you keep your appointments and, if you can’t, you let us know within enough time that we can book someone else. Each patient is allowed two appointments that they can miss with no notice because we recognize that sometimes cars don’t start in winter, people get sick and it took longer to try on your prom tuxedo than you had planned (a real reason). If you miss the third appointment, we close the file. We also expect people to get their bloodwork and other tests done and to try to remember to participate in treatment by doing their Cognitive Behaviour Therapy Homework or taking medication. My experience is that people accept this.
I am, therefore, truly mystified by governments’ reluctance to work with doctors to establish patients as full partners in this system by providing not just benefits but responsibilities. It seems that governments believe that expecting patients to be accountable limits patients’ freedom in some way or is not in the spirit of a “universal” health care system. I think that patients would welcome being told, “We’re working with doctors and hospitals to ensure that you have access to the best health care but we need your help managing this.”
I know that readers will have different views about patient accountability, and all of us have had negative experiences with inappropriate use of our health care resources, by any and all partners in the system. But we cannot just continue to ignore this.
It’s time to deal with the “elephant in the room”.