The Left Atrium
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The Left Atrium Battling the berserkers Many physicians will not like Shortt’s central message that the introduction of The doctor dilemma: public policy and the changing role integrated care will mean a shift from of physicians under Ontario medicare fee-for-service to some other form of re- S.E.D. Shortt imbursement. This is likely to be a mix McGill-Queen’s University Press, Montreal & Kingston; 1999 of sessional payments through an alter- 145 pp. $55 (cloth) ISBN 0-7735-1796-6 native funding plan for specialists at aca- $19.95 (paper) ISBN 0-7735-1794-4 demic health sciences centres and a modified form of capitation for family edical professionals wait ner- to point out that this term is often con- physicians. Some may interpret the pro- M vously on the shore, “divided fused with similar ones such as man- posed policies as an attempt to control among themselves and perceiving attack aged care, devolution, regionalization doctors, but Shortt maintains that they from without,” writes family physician and comprehensive health organiza- are about accountability, not control. A Sam Shortt in The Doctor Dilemma. tions, and he admits to using these in- clear message is that until physicians Imagine a Viking dragon-ship full of te r c h a n g e a b l y . learn to distinguish between the two berserkers from government, academia The book is well written, and Shortt they are unlikely to reside comfortably and the public, leaping onto the strand, is not afraid of a vivid phrase for em- in the Canadian health care system. brandishing their war axes. What will be phasis. There is an inevitability to each How will the dilemma be resolved? the outcome of this raid? Will physicians chapter as he outlines the issues, judi- Shortt argues that some form of inte- survive, huddled next to the driftwood ciously considers the evidence and grated care is inevitable and will likely be fire of medicare, or will they be forced to reaches balanced conclusions. Pub- for the better. He feels that the policy embrace a foreign culture imposed by lished evidence, where available, is put levers are already in place in Ontario and the marauders? Shortt’s answer is that a to good use, and the constraints im- that it is time for some strong political sea-change is inevitable and that assimi- posed by its lack are acknowledged. hands to start pushing them. As it hap- lation within a new culture will be the Two recurring themes are (1) that the pened, Norse culture spread peacefully best outcome for physicians. anomaly of public payment for private and gradually through Europe and the Shortt sets the scene by recounting practice has been directly responsible North Atlantic countries over several the amusing and preposterous attempt for the adversarial na- centuries. I rather by a disgruntled physician to force the ture of physician–gov- think that this is how a premier and the minister of health of ernment relations, and new system, whether it Ontario to undergo psychiatric assess- (2) that the days of pri- be called integrated ment for their inappropriate behaviour. vate practice are num- care or something else, He then considers five key policy areas: bered and will eventu- will be diffused. Al- payment of physicians, supply and dis- ally be replaced by ready, the Health Ser- tribution of physicians, quality assess- public payment through vices Restructuring ment in ambulatory care, the relation- some type of integrated Commission of On- ship between physicians and hospitals sy s t e m . tario is soliciting pilot and the role of technology. Although The Doctor Dilemma sites for integrated most of these issues are familiar, this will interest physicians health care systems. book is better than most accounts in who are puzzled about Physicians would bet- both its perspective and its thorough- how events seem to be ter serve the profes- ness. With his experience as a family overtaking them and sion and their interests physician, historian and policy analyst want to know where the profession is by becoming part of this process rather (he is now director of the Health Policy heading. Policy-makers anywhere in than having integrated care imposed on Research Unit in the Faculty of Medi- Canada who are mulling over the intro- them. The Doctor Dilemmahas the best cine at Queen’s), Shortt is well placed duction of integrated health systems interests of the profession at heart. It is to put these issues in context. The book should read this book carefully. Shortt worth reading for that fact alone. is rich with plundered treasure, con- strongly advocates a crucial role for taining over 400 references. It presents physicians in charting the future course Duncan Hunter, PhD a clear-eyed synthesis of an important of the health care system. No doubt Director, Health Information Partnership issue facing the profession, namely inte- there are one or two bruised bureau- Eastern Ontario Region grated care. Shortt is careful, however, crats who will beg to differ. Kingston, Ont. 6 2 JAMC • 13 JUILL. 1999; 161 (1) © 1999 Canadian Medical Association The Left Atrium Room for a view A line in the sand t was near the end of my first rotation tive. By now, she was comatose. asked to speak to the doctor on call. I Iin the intensive care unit. A ray of sun- Not only was her condition precari- was the one on duty that day. All I light shone into the ward through a win- ous, but the issue of confidentiality was could hope was that she would not ask dow; outside, the day was beautiful and problematic. Although she lived with her for the diagnosis. If she did, I would cloudless — quite a contrast to where I mother, she had not listed her as next of have to withhold the truth. stood. Twenty patients lay in the unit, kin at admission and had named two As I approached the room I could some with fractured limbs and vertebrae, friends instead. Their see her sitting, quietly res- others with overwhelming infection, whereabouts were un- olute, at her daughter’s bed- some comatose with cerebral edema, sev- known. Would she want side. She wore a colourful eral rubbing shoulders with death. her mother to know her dress and a simple sun hat. Among them was a young woman HIV status before she She looked as if she could who had come to emergency in acute did? What if she died be- have been sitting in the shade respiratory distress. The cause had been fore she learned her diag- of an oak tree on a warm Sun- identified: Pneumocystis cariniip n e u- no s i s ? day afternoon, sipping lemon- monia. Apart from having had several These questions were ade and chatting about the boyfriends over the past few years, she hotly debated by the weather. But she was there to had no risk factors for HIV. ICU team. We resolved that the house discuss her daughter’s condition. I was Her condition deteriorated quickly, staff on call would not tell the patient’s there to protect my patient’s right to but before intubation was needed she mother the underlying diagnosis that confidentiality. I was there to draw a had given consent for HIV testing. Af- weekend. We would hold a family line in the shifting sands of disclosure. ter intubation, her agitation prevented meeting on Monday and disclose the She looked at me slyly. It became a adequate oxygenation and required seriousness of her condition then. game of cat and mouse: pleasant chit- both muscle paralysis and sedation. The As it happened, the patient’s mother chat about her somewhat rebellious test result arrived: she was HIV posi- came in early on the Saturday and daughter was interspersed with probing qu e s t i o n s . “Doctor, please, if I may, what is the reason for my daughter’s bad pneumo- One thousand words ni a ? ” “This type of pneumonia is usually due to a weakened immune system,” I replied. My tongue was dry. “But just what kind of pneumonia is it?” she inquired. I told her the name. Her eyes narrowing only slightly, she formulated her next move. “Could all of this sickness be because of some sort of — what do you call them — virus? “Yes, that’s one possibility,” I ma- noeuvred, begging all the forces in the world not to let her ask outright if her daughter had AIDS. There was that line I was not to cross over. We paused, her inquisitive eyes rest- ing on my guilty face. I hated this. It was evident how much she loved her daughter. She was suffering unfairly and her anguish was made more acute by my limited disclosure. In a way, she was being made the fool. The entire Quarantine station, Grosse-Île, Quebec, circa 1900. ICU staff —all strangers to her daugh- ter — knew the diagnosis. Yet here she CMAJ • JULY 13, 1999; 161 (1) 6 3 De l’oreille gauche was, each day, watching her daughter gastric tube placement. Before leaving, done right, hadn’t I? die without knowing why. It became I asked her if there was anything else. So why did it feel so wrong? clear to me that she had the right to But the momentum was lost. She know, to make the proper preparations, looked almost resigned. I tried to reas- Rosaleen Chun, MD and to grieve. Perhaps she suspected all sure her by mentioning the family con- along the word I dared not utter and ference in two days.