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Green Shield Canada

Episode 19: Medicalization of healthy people

In Episode 19, producer Sarah Murphy and host David Willows welcome Dr. Danielle Martin to the podcast studio to discuss better approaches to health care.
And now for something completely indifferent

And now for something completely indifferent

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Episode 19 Transcript

[INTRODUCTION]

[0:00:14.9] SM: Hello and welcome to another episode of GSC’s Podcast; And Now For Something Completely Indifferent, where we’ll be discussing the hottest topics and trends in Canadian health benefits. I am the producer and editor, Sarah Murphy.

Before we get started with today’s episode, we would to remind our listeners that the views expressed in this podcast are those of the individual speaking and not necessarily the views of GSC. We may talk about possibly controversial subjects and therefore, reserve the right to potentially offend some listeners, but are apologizing for it upfront.

You can download this podcast from our website at greenshield.ca\podcast, or subscribe to it from wherever you get your podcasts. We also encourage you to read our publications, the inside story and follow the script and GSC talk, which you can also download from our website. Please be sure to follow the conversation on Twitter and LinkedIn.

Now let’s get started. Today’s episode is hosted by David Willows, GSC’s Executive Vice President, Innovation and Marketing.

[EPISODE]

[0:01:13.9] SM: Hello, David.

[0:01:14.6] DW: Hello, Sarah. We are approaching the end of summer and it is our first podcast for a couple of months. We actually, probably would try to do this in July or so when we had written an inside story about what we’re deeming unnecessary medicine, but we held back and waited to try to land this big fish, this interviewee.

[0:01:37.5] SM: Superstar.

[0:01:38.3] DW: Superstar doctor, arguably the most famous Canadian doctor right now. We have with us today Dr. Danielle Martin, who is the Executive Vice President and Chief Medical Executive at Women's College Hospital here in Toronto. She's also a family doctor.

[0:01:55.0] SM: Okay. Anything else she does?

[0:01:56.3] DW: Well, I want to say she's the winner of the 2019 F.N.G. Starr Award, which you and I have decided to rename doctor of the year, a little more understandable and the youngest ever winner of that. Somebody else that won that award probably many years ago was Sir Frederick Banting. She's up there with the insulin people.

She is a well-known advocate for our Medicare system. She's the founder of the Canadian Doctors for Medicare. She wrote a quite famous book a couple years ago 2017. It came up Better Now: Six Big Ideas to Improve the Health of Canadians. She is a person that is out there talking a lot about system change. She's probably most famous for a moment.

She maybe gets tired of hearing this, but back in 2014 she was a witness in front of a senate committee in United States when they were talking about Obamacare and health systems. She famously dismantled an under-prepared US senator. Anybody can come on YouTube and see that. Just type in Dr. Danielle Martin and you'll see that video. It went viral literally across the globe and put her really in the spotlight and she's used that to certainly advance her viewpoints in the Canadian context.

Also, if you want to see a good description of the book and the points in it, go to YouTube and there's a great interview with Steve Paikin from TV Ontario with her, because reading books is we know hard and it's exhausting. If you don't want to actually read the book, it's a great interview that goes through her six ideas.

Without any further ado, we were very lucky to get her and we were quite convinced that she knew nothing of this podcast when she agreed to do it. I think it went okay. Here's Dr. Danielle Martin.

[0:03:39.2] SM: Great.

[INTERVIEW]

[0:03:43.8] DW: I want to welcome Dr. Danielle Martin, not into the studio. We have our second phone guest. We think we've got this technology working now and it's interesting that both our phone guests have been physicians, which suggests that maybe they're busy and don't have time to come and sit in our silly little health and wellness room that has been converted to a podcast studio.

Dr. Martin, you said I can call you Danielle, so I will start doing that.

[0:04:06.9] DM: Of course.

[0:04:07.6] DW: All right, I just provided a rather elaborate resume to our listeners about your history. I would say you're probably one of the most famous Canadian physicians. In that resume, I talk about some of the work you're doing administratively at women's college. You are a family doctor. You're a great advocate for change in the healthcare system. You've written a best-selling book. At this point in your life, what percentage of your life is each of those things? How do you balance all of the things that you're involved in?

[0:04:34.1] DM: Sure. I mean, I would say poorly to begin with. I don't know that any of us ever really figures out what balance looks like, but I do consider myself a family doctor first and foremost. It's my core work identity, but it is for better and for worse a smaller part of my week.

Right now, I generally see patients on Monday mornings, Wednesday evenings and Friday mornings. I try to spread my limited availability through the week, so my patients can get access to me. Then the rest of the time, I'm doing administrative work, leadership work, helping to run the hospital and I still do engage in research and teaching and work at the university as well. I've got a bunch of different hats that I wear.

I do think, although it's a bit hectic with the running back and forth and you never really feel you've got it quite right, I do think that two categories of the roles are synergistic, in that I have a pretty good sense of what it feels like at the frontline to be seeing patients on a daily basis and what the frustrations of that are. I can carry that understanding and knowledge, even though it's not a full-time knowledge, into my administrative role, that makes me, I hope, a more effective leader for change.

[0:05:51.5] DW: Absolutely. I'm sure of that. Sarah knows that in our team here and our strategy team inside Green Shield Canada, we have specifically a pharmacy strategy team that works on drug formularies and such and we have pharmacists that work in our team. They still go in on weekends and do some of that work, both in hospitals and retail and it certainly adds a lot to the strategies we're able to enact and that probably more sensitively address the needs of plan members.

Let me talk a bit about your big book, which came out in 2017 called Better Now: Six Big Ideas to Improve the Health of Canadians. You are one of the leading people putting out new thoughts about the system and how it can evolve over time. It's been two years since 2017. I'm not going to make you recite all your six big ideas, but are any of them gaining traction? Have you seen any material change in any of your six ideas here two years later?

[0:06:44.6] DM: Yeah. I mean, one of the things that I try to be super clear about in the book is that although I'm putting forward the six ideas that I think have the best chance of improving Canadian healthcare, none of them are my ideas. Most of them are ideas that are – they're well-founded in evidence, they've been well-researched and bits and pieces of them are being implemented in bits and pieces across the country. What I'm trying to do is to lift and elevate those ideas to get traction on a bigger scale change agenda.

[0:07:19.1] DW: Fair enough.

[0:07:19.7] DM: As always happens with these things, I would say it's one step forward, two steps back. At the time that I was writing the book, which was back in 2015, 2016, I thought that the idea that was most likely to get me labeled a lunatic was the basic income guarantee. The notion that we should be changing the way that we think about income supports, because we know that income is the most important determinant of health in a society.

I was trying to raise public awareness around the extent to which poverty actually drives health outcomes in Canada and that if we can fix our income supports, we can do a lot for people's health. I thought that that would be seen as a pretty marginal idea in the mainstream policy conversation, but not that long after the book came out. I'm not saying it was because of my book.

The former government of Ontario announced a three-year basic income pilot project. We now have leaders in Quebec who are really big advocates for this approach. We've got huge conversations happening in the US and across Europe about the notion of a basic income guarantee. Now the Ontario pilot was then subsequently cancelled, but my point is just there are conversations happening in places that I could never have anticipated at the time that I was writing.

Similarily with the pharmacare conversation, which is my big idea number two, national pharmacare for all Canadians. I could never have predicted the extent to which that would be taking off as a possible election issue, as a key core election part of the election debate for our upcoming federal election.

Yet, some things seem really hard to move. I know that we're going to talk about some of the areas around inappropriate and harmful and wasteful tests and interventions. There's not a single button that someone can push to fix those problems. The interventions required are much more complex. I would say there's been progress on each of the big ideas, but I certainly don't think I can retire yet.

[0:09:24.0] DW: Okay. Good. Your patients need you too. Let me zero in on the one that we're particularly interested in today. A periodical – we call it The Inside Story, is about to come out as soon as we edit this podcast, as a companion to it. It talked a fair bit about what may be deemed unnecessary medicine that happens inside the system. We quote you in there. It says, every year, millions of Canadians are harmed by unnecessary inappropriate and harmful and wasteful medical tests and interventions. We need to stop talking only about the benefits of healthcare and start talking about the harms.

That's probably a unique voice coming from the physician community. I'm sure it's not the only one, to be fair. When you say things like that, I'm interested. Inside the physician community in Canada, is that at all controversial, or is there a general acceptance, yeah, there's a problem, but the bigger issue is how do we stop doing these things?

[0:10:19.7] DM: I think that there's a growing awareness in the medical community about the amount of harm that is done by unnecessary and wasteful tests and procedures. I think that of course, it's so often terribly unfortunate these horrible things happen at the hands of other physicians, but not me, right? Of course. That’s I think part of where medical culture is like the culture of every other profession and workplace in that it's really hard to look at oneself and one's own practice patterns and identify the ways that each of us as individuals is contributing to these big-ticket statements, such as the CIHI report that came out I guess, about a year and a half ago now, that indicated that up to 30 of the tests, treatments and procedures at least in some categories in Canada are potentially unnecessary.

If you think about the potential impact on the health of people from having that much unnecessary and potentially harmful stuff being done to them, diagnostic procedures, prescriptions, interactions with specialists, time away from work, unnecessarily labeling, over diagnosis, the list goes on and on. That's very significant. The question is what do you do about it?

You look at a campaign like the Choosing Wisely Campaign, which many of your listeners may be familiar with. Choosing Wisely has had a tremendous impact on the medical profession internationally. It is a campaign that is all about changing the conversation between doctors and patients, or healthcare providers and patients about the care that we give and rebalancing that conversation to think about harms and not solely about potential benefits.

It's not a conversation about cost. It's not a conversation about wasted dollars. It's a conversation about harm to people's health that comes from unnecessary care. Of course, there's also a financial impact on our healthcare systems if we're not spending the money the way that we could be. The problem is that big sledgehammer type policy tools for nuanced problems like these are very difficult to implement.

I do think in answer to your question, that there is a growing awareness among physicians and hopefully the public that this is a problem, but not a lot of really sophisticated solutions yet for the issue.

[0:12:54.0] DW: We like to try to keep things real for our listeners here. Even in just an everyday family practice, what are some of the common things that maybe even aren't harmful, but maybe just unnecessary that are just par for the course in your mind in the system?

[0:13:08.2] DM: Sure. Well, it can be anything from a screening blood test. I have these conversations very often in my own practice; a person comes in, a woman will come in for a routine pap smear and say, “Should I have a bone density test? I'm 55 now. My friend had one. Or should we check my iron?” “Well, are you feeling well?” “Yeah, I feel fine, but you never know. I could have low iron.”

We see tests like that, where that person feels well and there's no medical indication for the test, all the way through to one of the most common ones that we see in primary care which is imaging for common conditions, such as low back pain. “My back's been hurting. It's been two weeks. I thought it would get better by now. I went to see the physiotherapist. My neighbor had the same problem. He had an MRI. Shouldn't I have an MRI also, or a CAT scan, or an x-ray, or whatever?”

Those conversations are I mean, the examples I've given you are patient-driven, with patients asking. Of course similarly, there's lots and in fact, probably more physician-driven step where you're sitting in the office and you think to yourself, “Well, I'm checking this person for diabetes anyway. I might as well just while we're at it, throw in a cholesterol and make sure your thyroid is okay.” It's that itch to tick the box that I talk about in my book, that it's such a simple act, the checking of a box to submit a person to a medical test, simple from the physician’s perspective, maybe not so much from the patients.

The ripple effect in that person's life can be tremendous. If all of the things that lead me to that moment of ticking the box from my undergraduate training, to my medical training, to the social expectations, to what I learned in medical school that may now be out of date, to what I think my patient wants, or I believe my patient would be disappointed in me if I didn't do all that complexity, how much energy I've got for the conversation...

All of those things lead to that very simple act of ticking the box. How are we going to unpack, untangle all of that to put in place effective interventions to prevent me from putting that person in harm's way, thinking that I'm helping them?

[0:15:19.7] DW: Yeah. Are you a bit of a poster child for saying no to a patient?

[0:15:22.9] DM: Oh, I would say I have my good days and my bad days like everybody else. So often, of course, it's not the patient I'm saying no to, it’s myself. It's that little voice in the back of my head. Well, what if and could it possibly be and should I just, you know, to be on the safe side. Of course, we never think about what the safe side is in terms of unnecessary testing and harm. We were all conditioned to think about the safe side as being overdoing it over, over-checking, over-testing, over-treating.

Oh, it's probably a virus, but it's possible it could be a bacterial. Should I just prescribe an antibiotic to be “safe”? Not thinking about either the antibiotic resistance that could result, or the harm to the person who then gets diarrhea for two weeks, because they've had an unnecessary course of antibiotics, etc., etc. There's a conversation with the patient and then there's a conversation with my own instincts about these things that has to be continually had. It's not a one-time thing.

[0:16:24.0] DW: I mean, you're being very honest about the human condition and personalities that live inside all of us. How do we ever enact system-wide change if we're dealing with physicians who are deeply human and not always – I would even say rational in their decision-making, more than any of the rest of us when this is a problem that's out there?

[0:16:47.6] DM: I think that it is of course a culture change. I think that one of the ways that we do that and this is why I wrote the book and why I do so much public speaking about these issues is because part of this is about us learning to ask our patients and the public to help us change that culture. One of the things that I've learned from my own practice is from the experience of the the again, to use our bone-density example, the woman who comes in and says, “Well, I'm 55. Should I have a bone density test?”

I have that moment of screwing up my courage for the conversation and I say, “Actually, you don't need a bone density test. Let me explain.” Pull out the decision tool and show her, “You don't have any of these risk factors. You don't need it until you're 65 at anticipating a real interchange.” She says, “Great. I had better things to do next Wednesday. I didn't really want when I was just asking if I need one.” Realizing actually, I mean, I share some stories in the book of people who've had horrible outcomes as a result of unnecessary interventions.

Helping people to understand that there are real risks. You don't want a colonoscopy if you don't need a colonoscopy. You don't want a dress test. Right. I mean, but it's amazing how we think well, could you possibly have colon cancer? I mean, so and we could rebalance a conversation and we need to ask the public to put that pressure on us in order to begin to change that balance of pros versus cons, or risk versus benefits, because everything in life has risk.

It's only by changing the public's view to understand that sometimes that too much medicine is bad for your health, that's what's going to help the medical community to come around, I believe.

[0:18:42.2] DW: Do you think the Canadian public is too proud of and uncritical of the system?

[0:18:47.5] DM: I think we are proud as we should be appropriately proud of the values that underpin the system. The notion that access to care should be based on need, not ability to pay. The notion that the person who gets served next in the system should be the one who needs it the most and that wealth shouldn't guarantee people access to something faster, or better than someone who's sicker. The idea of justice and fairness that underpins that, I don't think you can ever be proud enough of those values.

Where we run into problems is when we are then unwilling to be critical, or demanding of the system to live up to those values. To deliver a great experience for each of us and for our loved ones and family members when we need it. I think we need to separate the values from where we fall short in the implementation, so that we can spend our energy and time working to live up to those values. I have no interest in solutions to our problems that are going to leave other –leave people behind. I want to see problems solved in a way that's equitable for everybody.

Let's be real, there are problems. We've got problems with wait times for our access to care. We've got problems with inequitable access for people who live in rural communities. We've got people who are choosing between paying for their rent and paying for their insulin. We've got horrible health outcomes in indigenous communities. The list goes on. We're not going to make those things better by pretending that everything is okay. When we get to talking about the solutions, let's make sure that we pick those solutions that elevate those values that we’re also rightly proud of.

[0:20:32.7] DW: What do you say to people who would contest that the compensation system for physicians dissuades them from really adapting, evolving, changing the system?

[0:20:45.1] DM: Oh, I totally agree with that critique. I think the problem is that the – and I have some, I would say reasonable grasp of the International literature on this. There is no good way to pay a doctor. Every system has its pros and its cons.

The classic critique, for example of fee-for-service medicine, which I agree with and which is still the dominant method of payment for Canadian physicians is that it encourages a treadmill, pumping people through, it doesn't necessarily reward complexity. It may actually contribute to the epidemic of over testing and over intervening, both because doctors get paid to do interventions and because it takes more time to talk to someone, than it does to just order a test, etc. There's a long, long list of critiques of fee-for-service medicine, much of which is supported by evidence.

The critiques of salary, often have also been supported in the literature that physicians on salary see lower volumes of patients. Well, maybe that's because they're giving really good quality care, but in the system where we have wait times, people raise really legitimate concerns, I think about what would happen if suddenly the average physician were to drop their volumes or their productivity by a quarter, or whatever it is.

The critiques of payment for outcomes, payment by results are that they provide a perverse incentive for physicians to take on healthier patients who are going to bump up their numbers. Now, I won't see a low-income person, or a person who smokes, or a person who's more vulnerable because they're less likely to be “compliant,” or adherent to my plan and they're going to mess up my statistics and that's going to affect my income.

It turns out actually, that there is no perfect way. We haven't found one yet. Probably a hybrid model of some kind that acknowledges that different physicians playing different roles in the system may need to be remunerated for different kinds of things is where we need to end up, but that's a super complex exercise to try to figure that out.

[0:23:02.0] DW: We will not figure that out today. I will say, since we've been talking a lot about physicians and the need for change and systemic change, I was interested in asking you, because we are quite obsessed in our industry a bit about our relationship with physicians and feeling we don't have a good one. How can we connect into that community and see if there are changes that we can make communally together, to better the experience of our plan members and your patients? What's your take on working with insurance companies? I know you didn't go to school to fill out forms, you wanted to heal the sick, I think, but you probably have a lot of forms in front of you. What do we add, or distract you from?

[0:23:40.1] DM: That's a thoughtful question. I think that my – as a clinician, there are two ways that I experienced the insurance company. The first is the sense of relief that I get when I learn that my patient has “good employer-based insurance,” that will cover whatever aspect of their treatment plan that they – I feel they need that isn't covered by the public plan. Yes, I can send you for physio. Yes, I can give you this prescription. Yes, I can send you for psychotherapy and somebody's going to pay for it. I mean, it's an incredibly – it's a big relief to a clinician to know that our patients have access to that.

I will say that sometimes, the insurance conversation in that context I think does contribute to epidemic of overuse, because we've all been conditioned, doctors and patients and insurance companies and employers to think that the “good plan” is the one that pays for everything no matter. Actually, a plan that pays for everything, for everyone all the time is not a good plan.

[0:24:50.9] DW: That's music to GSC’s ears.

[0:24:53.3] DM: Right. Right. It invites a blank prescription, instead of a thoughtful conversation about what is actually going to improve health for this person in this circumstance. The bigger the gap between those who have private insurance and those who don't, the more we develop this sick aspiration to have insurance that pays for everything that our public plans don't cover. Actually, we don't want to live in a society that consumes that much healthcare, I don't think. I mean, I certainly don't.

That's a tricky one. That I think is a place where there could be a really productive conversation between the medical community and the insurance industry. Then the second place where I interact with insurance companies that is more difficult is around disability and sick benefits, where people are not able to work. There, I just feel terrible for my patients who are sick and having to navigate the maze of paperwork, that sick people have to navigate in order not to miss their rent payment this month.

This I talk about in my book and the question about the basic income guarantee. Because I really think that we have – we ask certainly people on social assistance. We turn their lives into a maze of bureaucracy when what they need is to get out of poverty. Our goal seems to be to screen out people, instead of support people when they're down in a vulnerable time in their lives.

I have no idea how one goes about dealing with that in the insurance industry. Certainly in our public income support programs, it's a real problem, because you could spend your whole life as Hugh Siegel has said, behind plexi-glass trying to interact with a bunch of systems that actually were not built to help you. It's not a good place for Canadians to be.

[0:26:53.8] DW: Yeah. No, I spent a good part of my career, the early part of my career on the the disability management side and it's often not a happy place, and trying to find the balance of being an insurance company and obviously having a person that's very much in jeopardy. We still haven't cracked that code on how to make that a truly humane and probably balanced system. Look, I’ve taken up a lot of your time. It was music to our ears to hear you talking about benefit plans that pay for everything, because we probably been most vocal about questioning some of the things that have long existed in standard benefit plans.

Look, we make money from reimbursing them. That's how we make our money and we've still said, are we sure we're getting value from those? If you ever want to add to your resume and perhaps move over to the insurance industry, I would call you to be our medical director if we ever create such a position. I’m not sure –

[0:27:46.6] DM: If things don’t work out here, I’ll keep that in mind.

[0:27:48.5] DW: I’m not sure that's going to be top of your list, but know that that's there in the background. Thank you very much.

[0:27:52.8] DM: Thanks so much, David.

[0:27:54.5] DW: Yeah, it's great talking to you.

[END OF INTERVIEW]

[0:27:59.4] SM: Thank you to our listeners for tuning in to another episode of And Now For Something Completely Indifferent: A Canadian Health Benefits Podcast.

To be sure to get feature episodes, please subscribe to this podcast wherever you get your podcasts, or visit our website at greenshield.ca\podcast to download.

As a reminder, we talk about these issues consistently in our publications, which are available on our website, as well as on social media. Be sure to follow the conversation. For today’s episode, be sure to check out our August-September issue of The Inside Story.

Thanks for listening, and we’ll talk again soon.

[END]