The meetings of the premiers in Fredericton and a recent piece in Forbes, a leading US financial newspaper reminds me of my father’s frequent statements about medicare. He owned his own business, a bill collection agency and was well right of centre on most things but an avowed left winger on Medicare. He was inordinately proud that people in Canada had medicare because so many families before Medicare used to have to pay for health care in Canada and he learned from his business colleagues that many families in the USA were crippled by medical bills. Forbes restates that one third of Americans struggle to pay medical bills and medical bills are the number one cause of bankruptcy in the USA.
I want my health care to be personalized AND I want it standardized.
When I go to my doctor, I want her to treat me like an individual who has different wants and needs than her next patient. Even though she may spend only a few minutes with me, she makes me feel like a unique person. She remembers who I am and the challenges I am facing. She doesn’t just dispense medical care; she cares for me as a person.
But I also want my health care to be standardized. If I suffer from a specific illness, I want to be able to get the best scientifically validated treatment for that illness taking into consideration my specific preferences and needs. I don’t want to be given my doctor’s favourite treatment if that is not the best and validated treatment approach.
The delivery of health care is often not standardized. Different patients will be offered different approaches for the same health problem. For a given problem, some patients will be hospitalized while others will not; some will get surgery and others will have a medical treatment instead. This makes a lot of sense if the variation is based on variation in the illness or the patient, or even variation in the patient preference.
These variations in care are often based on what the health care provider prefers. Preference may be because of the way he or she was trained or past experience. This is not a good idea unless the health providers preference is for the best scientifically validated treatment. Whenever there is large variation in treatment for the same problem, it indicates:
1. We don’t have good scientific evidence to prove what the best treatment is, and thus there is no “preferred” treatment.
2. Some care providers are giving inferior treatment by using their preferences instead of the “gold standard” or evidence based treatment.
3. There is evidence that two or more treatments are the same and then it doesn’t really matter which is used.
I used to think that this was true only in my own field of child mental health. In many cases, you could predict what treatment a child was going to receive by looking at the preferences and biases of the health care provider rather than the child’s health problem. So for example, if your nine-year-old child had severe anxiety and panic attacks that were preventing them from attending school, professionals trained in family therapy would offer family therapy, psychoanalysts would do psychoanalysis, cognitive behavior therapists would do cognitive behavior therapy and physicians would prescribe one or more drugs. This wide variation in treatment is unacceptable.
Wide variation in treatment in the health system is a signal that decisions are being made without the use of evidence.
Two issues that we have to grapple with in these variations are because of skills, knowledge or experience of the health care provider and cost of the treatment.
If an intervention requires a certain type of skill that the health care professional does not have, then the solution needs to revolve around the patient preference. Clearly defined options should be given to the patient. “The research suggests that ABC treatment is about 10% more effective and I can refer you to Dr. Y. I can treat you with XYZ approach which is pretty good but not as good as ABC.
If treatment is varied because of the values, needs or preferences of the patient, that is appropriate as long as the patient understands the options. For example, a treatment that can be administered with a daily pill might be chosen over a more effective treatment that is delivered by means of a two hour intravenous treatment in a hospital (especially if the patient has to travel two hours to get the treatment). Similarly, a treatment that has fewer side effects might be chosen over a more effective treatment with more side effects. The key is that variation should be for the patient’s best interest as judged by the patient. Consequently, a full discussion about the advantages and disadvantages of each treatment option is needed.
Treatments that cost the health system will usually be chosen over more expensive treatments so that more patients can be served. Day surgery is now used for problems that used to require hospitalization. Generic drugs are often prescribed instead of brand name drugs. If a patient’s insurance will pay for a more expensive alternative, this is often possible.
What can you do to ensure that you are being offered the best treatments possible?
1. Ask questions about the treatment that is being offered to you. Questions you could ask include: “Is there good evidence that this treatment is effective?”; “What are the other alternatives to treating my health problem?”; or “Can you suggest something for me to read about this treatment or alternative treatments?”
2. Use trusted sources to look up information about your treatment. One of the best sources is Medline Plus, the National Institutes of Health, health information portal. It provides information and links to other sources. Well known health charities such as the Canadian Cancer Society and the Heart and Stroke Foundation. Avoid any website that is selling anything.
3. If you are unsure and the situation is serious, you may want to ask your doctor to refer you for a second opinion.
~Dr. Patrick McGrath
When I was growing up as the second oldest of ten kids, we didn’t have dogs or cats. My mother always said she had enough kids and didn’t have time to take care of a pet. My mom did allow us to have turtles. I guess she figured they were easy enough to care for. If I remember right we changed the water once every three days. Our turtles were in a small circular plastic container with a ramp that the turtle could come up on and a beautiful green plastic palm tree. We fed our turtles raw hamburger.
In most respects, my mom was a genius. She taught me most of what I know and kept all of us from killing each other. But she was not right about pets. Dogs and maybe cats are good for our health. Turtles are bad.
Turtles are bad because they are an infective reservoir for salmonella, a very nasty bug that can kill. Apparently Agriculture Canada banned importation of small turtles into Canada in 1976. The turtles that I remember were actually red-eared sliders (Trachemys scripta elegans). Unfortunately for the turtles, my brothers and sisters and I led to the demise of many of these cute creatures. None of us ever had a serious infection from them, although I am sure we did not wash our hands each time after touching them.Now what about dogs and cats?
There are several reasons certain pets are beneficial, but first I must disclose a conflict of interest. We currently have both a cat and a nine-month-old standard poodle. Murphy, our poodle, is energetic and a real help in me getting my 12-15,000 steps a day. I walk him in the morning, usually about three thousand steps and then my wife and I usually walk the waterfront, about 4,500 steps.
There is good scientific evidence that having a dog can help you get moving. But not everyone who owns a dog walks it and aggressive dogs in a community can inhibit walking by non-dog owners. Most cat owners don’t walk their cats and sitting with a purring cat on your lap may make you feel loved, but it won’t help your activity level. The literature on the effects of dog and cat ownership on depression is mixed. In some studies, cat owners had more depression and death following cardiac events. I certainly understand this. They must have had a cat like our cat. Maska tries to bite me when I try and pet her. .
The American Heart Association did a very thorough review of pet ownership and cardiovascular health. They found that pet ownership especially dog ownership was related to better heart health. But they cautioned that the evidence is not strong enough to get a dog for that reason. Unsupervised and especially roaming dogs are a risk and a particular challenge in some communities especially in remote areas of Canada.
Dogs are also great for meeting people. Every day, a half dozen people want to say hello to the dog. Actually, very, very few of them want to get to know me.
But the evidence that I like best is that dog and cat ownership may strengthen the immune system and reduce allergies. The evidence for dog ownership is that dogs do not increase the risk of allergic response and may even prevent allergies. For cats, some studies find an increase in allergies and some studies find a decrease. As someone who suffers from animal allergies, we chose a poodle and a Devon Rex cat because they provoke my allergies less.
This finding fits with other research and the “hygiene hypothesis” which I like to call the dirt hypothesis. The hypothesis is that some microbes especially those that co-evolved with humans may be protective against many autoimmune disorders from inflammatory bowel disease to multiple sclerosis. I like to interpret the research data more broadly to suggest that a clean house is a sign of a wasted life. My wife concurs that I have not wasted my life.
Editorial note: There may be selective citation of scientific literature about cats and housework by Dr. McGrath to justify his proclivities.
~Dr. Patrick McGrath
By Bill Tholl, President & CEO, HealthCareCAN
Did you know that between 2012 and early 2014 research success stories from Canada’s academic healthcare organizations were featured over 5,600 times in mainstream Canadian print media?
True to form, we are all too modest when it comes to our prowess in health research. Canada is the home of major discoveries from stem cells to insulin; from vaccines to technologies that help the elderly and those with disease and disability. We need to build on this tradition of research excellence, making sure that our research is celebrated and used in the delivery of care.
So what are the winning conditions for advancing health research? First, we need to agree on what success in health research looks like. What are the desired outcomes from our overall research investments? At HealthCareCAN, the national voice of healthcare organizations, we use the IHI’s “Triple Aim Framework” to define research success in terms of “better health, better care and better value”.
Who is responsible for advancing this vision? According to a survey from the Healthcare in Canada group, Canadians expect government, academic healthcare organizations, and pharmaceutical companies to work together to bring new health innovations into practice.
The Federal Government must ensure that Granting Councils, like the Canadian Institutes of Health Research (CIHR) and the Canada Foundation for Innovation (CFI) have sufficient funding to attract and retain the best talent. Canada currently stands 6th in the world in terms of the total number of influential researchers. In the global race for talent, we need to keep researchers here. Administrators must then ensure that long term health research and development (R&D) budgets aren’t sacrificed at the expense of the short term imperatives of bending the healthcare cost curve.
But achieving results is not just about sustaining the funding for health research.
Decision-makers must step up their efforts to accelerate the use of new knowledge into practice: ‘moving from innovation by accident, to innovation by design’. The Advisory Panel on Healthcare Innovation recently announced by the Minister of Health, the Honourable Rona Ambrose and chaired by Dr. David Naylor, is a great example of an effort to do this nationally.
It is also about ensuring that we have the capacity to use the research generated to improve care. This is why academic healthcare organizations are so important. It is in these organizations that the infrastructure is created to bring new research and innovation safely into practice for the first time.
As an example, a few weeks ago, the Federal Government awarded Capital Health in Halifax, $2.9 Million to advance imaging research. The organization had already made a commitment in this area. The additional funding will advance new automated MRI technologies for objective decision making in the clinical diagnosis of several diseases, including brain cancer and prostate cancer.
Are there other examples? Yes. At HealthCareCAN, we look forward to showcasing such successes through an Innovation Sensation database this fall, funded by CIHR. This will help to celebrate the great Canadian tradition of health research, find and maybe even spread those innovations that can help us achieve better care, better health, and better value – winning conditions for all!
~Bill Tholl, President & CEO, HealthCareCAN
HealthCareCAN is the national voice of healthcare organizations across Canada. They foster informed and continuous, results-oriented discovery and innovation across the continuum of healthcare and act with others to enhance the health of all Canadians; to build the capability for high quality care; and to help ensure value for money in publicly financed, healthcare programs.
IWK Health Centre, Halifax, Nova Scotia
QEII Health Sciences Centre, Halifax, Nova Scotia
“Wow! That’s amazing. I never even suspected that.” This is the typical comment I get when people find out about the research being done at our academic health science centres, the QEII and the IWK. Each year, hundreds of studies are done here. Most are done in a very effective partnership amongst the health care system and the university system, usually Dalhousie University.
Research ranges from basic science through to clinical and implementation research. Physicians, psychologists, nurses, physiotherapists, occupational therapists and many other health professionals are involved.
Research benefits patients in many ways. First of all, patients get exposure to the best and latest treatments because of research involvement. When you are on a clinical trial, you have more people on your team looking out for your health.
The opportunity to do research is an attraction for the best and the brightest specialists. Many would not come to or stay in Nova Scotia without this opportunity.
Clinician-scientists are up on the latest and best developments in their field. If you have a serious illness, would you like to have world expert knowledge at work caring for you? That happens all of the time at the IWK and the QEII. Even having the hospital you go to involved in clinical research trials may improve your outcome, even if you were not in a trial yourself.
About $35-40 million dollars are brought into Nova Scotia each year by health centre research. So health research is good for the economy. Most of that money is spent on research staff which creates well paying jobs here in Nova Scotia.
There are also spin off companies and licensing agreements that bring in money and jobs to Nova Scotia. In my own research, our spinoff company, the not-for-profit Strongest Families Institute, delivers mental health care at a distance to over 2000 families a year across Canada and employs 30 people here in Nova Scotia.
Health research done in Nova Scotia has and continues to improve the health of Nova Scotians. A healthy population is more productive and pays more taxes but more importantly, individuals and families have years of additional quality of life. The truck driver in Yarmouth who got better care for his stroke and was able to return to work benefitted from research done in Nova Scotia. The pregnant woman who was vaccinated during pregnancy and avoided catching the flu, and perhaps dying benefitted from research done in Nova Scotia. The child cancer patient whose treatment was effective benefitted from research done in Nova Scotia.
Health research in Nova Scotia is a partnership. We partner with the funding agencies such as the Canadian Institutes of Health Research (CIHR), the Nova Scotia Health Research Foundation, health charities who support research such as the Heart and Stroke Foundation and companies that we contract with. In addition we partner with generous donors who give money to advance research through the QEII Foundation and the IWK Foundation. Without their support, local researchers would not be competitive in national competitions. The IWK and QEII Foundations often have articles about local research in IZAAK and the QEII Times.
I will devote some of my future blogs to featuring research that is making a difference to patients in Nova Scotia.
~Dr. Patrick McGrath