The Left Atrium

Even more frustrating, however, is On policy and cherries the selective use of data. More than one Better medicine: reforming Canadian health care chapter refers to the RAND Health In- David Gratzer, editor surance Experiment, a massive trial of Toronto: ECW Press; 2002 several health insurance models in the 326 pp CDN $19.95 (paper) ISBN 1-55022-505-7 US. A single result from the study — that families assigned free care used ost medical students would put ple, no data are presented to buttress more services but had equal health out- M their feet up after publishing a the claim that the Pearson health insur- comes compared with those in the user- single article, let alone an entire book. ance scheme, implemented in 1968, be- fee group — is used to argue that a Not David Gratzer. came “hellishly expensive.” In fact, Canadian-style health care system is in- Gratzer, now a psychiatry resident at OECD data show that Canadian health herently inefficient. Better Medicine fails the University of Toronto, has followed care expenses rose from 5.4% of GDP to mention, though, that the RAND Code Blue: Reviving Canada’s Health in 1960 to 6.2% in 1967, and from study excluded both elderly and chroni- Care System (written while Gratzer was 6.5% in 1968 to 7.1% in 1980. The ar- cally ill people. Within their robust a medical student at the University of gument that health insurance was re- population, when the RAND investiga- Manitoba, winner of the $25 000 Don- sponsible for the latter increase but not tors focused on the 25% of patients ner Prize and now in its fifth printing) the former is not persuasive. with risk factors such as hypertension with Better Medicine: Reforming Cana- Wente’s chapter of anecdotal stories, or elevated serum cholesterol, they dian Health Care. most of them familiar to Globe and Mail found that those offered free care were In many ways, Better Medicine makes readers, is perhaps the most powerful of 10% less likely to die. This is not an for a better read. Compared with Code the book. The tale of Christian Yau, a isolated misrepresentation. Three Blue, it is less repetitive and more me- motorcycle accident times, Better Medicine invokes a Harvard thodically referenced. The layout is victim who lan- study (name-dropping each time) to tidy, and a wider range of topics is dis- guished for 12 hours claim that Canadian physicians cussed. And, instead of relying solely on in the emergency rank our system poorly in terms his own analysis, Gratzer has assembled department of a of waiting times and quality. a distinguished group of essayists, rang- Vancouver hospital Unmentioned is that Canadian ing from economist William Watson to before being air- doctors in the five-country newspaper columnist Margaret Wente. lifted to Seattle for study were also least likely to Gratzer is correct to say that his emergency surgery, say that their health contributors are “deft with a pen,” but is infinitely more af- care system needs his claim that they span the political fecting than a flotilla Fred Sebastian an overhaul. Cana- spectrum would be insulting if it of bar graphs and dian physicians weren’t so absurd. The biographical tabular data. were also least likely to say that patients notes for well over half the contributors Other chapters are less compelling. are having difficulty affording out-of- mention ties to right-leaning organiza- Demographer David Baxter claims that pocket expenses. tions. This homogeneity swiftly carries the age of a “typical” Canadian will rise The varied contributions from Better Medicine toward its inevitable, fi- from 36 in 1998 to 68 in 2030. Readers Gratzer’s team set up the editor’s one nal chapter on the benefits of medical will be misled by the use of the lay ex- big idea, presented in the final chapter, savings accounts. Code Blue readers will pression “typical” for the statistical term that medical savings accounts (MSAs) recognize this terrain. “mode” and equate “typical” with “aver- will solve our health care woes. Al- But back to the beginning. After a age,” as Gratzer himself does in his in- though a panoply of options exists breezy introduction (thankfully, Grat- troduction. The chapter “by” William within the MSA model, the basic zer keeps this book mostly jargon-free), Orovan, former president of the OMA, premise is simple: patients — or con- historian Michael Bliss describes the is a transcribed interview. Gratzer sumers, if you will — would pay for evolution of health care in Canada from should have heeded Sir Francis Bacon’s small expenses out of an account desig- Confederation to the 21st century. This advice that “reading maketh a full man, nated for health care purchases. A fi- chapter, informative and erudite (as we conference a ready man, and writing an nancial incentive would encourage would expect from Bliss), dispels some exact man” and asked Orovan to write thrift, and catastrophic expenses would myths but propagates others. For exam- the chapter himself. be covered by insurance. The crucial

CMAJ • JULY 23, 2002; 167 (2) 173

advantage of MSAs, as Gratzer puts it, tion: hospitals competed not by lower- early diagnosis and prevention? is that they “would reinvigorate the ing prices but through marketing and by Should you read Better Medicine? It doctor–patient relationship with finan- offering the latest fancy doodads. Yes, depends on your outlook. If you share cial ties.” health care spending fell by 27% in two Gratzer’s ideology, you will delight in Gratzer should be commended for Chinese cities after the introduction of his analysis and enjoy his contributors’ attempting to freshen the sometimes MSAs, but this may have been the result clear prose. If you find yourself on the stale health care debate in Canada, and of concurrent reforms that limited the other side of the political spectrum, you MSAs do deserve close scrutiny. Again, use of imported drugs and expensive di- will benefit from giving Better Medicine however, Gratzer cherry-picks the data. agnostic tests. a critical once-over. But the ideologi- Yes, Singapore (where everyone has an In the end, Gratzer leaves the most cally unattached must continue to wait MSA) spends less than 4% of GDP on important health policy questions for the great, unwritten health policy health, compared with more than 9% unanswered. For example, how do we book that explains it all. for Canada. But Singapore has always structure our health care system to spent less than Canada; in fact, health deal effectively with chronic and pre- Irfan A. Dhalla care expenditures rose faster after the ventable illnesses like obesity and dia- Medical Student introduction of MSAs than before. This betes? How do we shift resources from University of Toronto seeming paradox has a simple explana- often futile end-of-life treatment to Toronto, Ont.

Room for a view Alone

he first time I attempted to raise Tthe dead was during my pediatric residency, when I was summoned to deal with an otherwise normal newborn infant who simply refused to breathe. The nurses offered the laryn- goscope and endotracheal tube while I bagged the baby, trying to persuade her to start living in this world. After the elapsed time that this furious ritual required, I looked at my watch and de- clared the end. I then tried to understand what had happened, and why. I had to convey to the distraught young mother that I had done all that was necessary, but it simply hadn’t worked. But fate was cer-

tainly looking at this episode differ- Fred Sebastian ently. The resident colleague who relieved me shortly after the incident In all of my other resuscitation at- her chair. But the music was too much, noticed that the sheet covering the de- tempts I was on my own. The second and the impulses of youth took over. ceased baby was moving rhythmically. one occurred during an otherwise bor- She had joined the dancing crowd and, He called me on the phone to declare ing on-call evening at the chronic dis- before long, suddenly dropped to the laconically, “You remember Baby ease facility of our hospital, where we floor. I reached her side, diagnosed Smith? The one that just died? She’s normally did very little except authorize cardiac arrest and screamed (yes, okay now.” I ran up the three flights of a change in medication dosage. I re- screamed) for the resuscitation cart. stairs to the newborn nursery. The ceived an emergency call to the play- Her sick friends were a sea of faces baby was pink, breathing and alert, and room, where the adolescents were hav- above me as I tried to initiate the resus- all that was left for me was to tell the ing a party. A young girl with citation ritual alone. By the time the amazed and delighted mother that rheumatic heart disease had been al- cart arrived it was too late. There was there had been a slight mistake. lowed to attend as long as she rested in nothing left to do.

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