Interview with a Canadian

The following is an interview I found interesting, between radio talk-show host Thom Hartmann and Dr. Lewis Mehl-Madrona, the author of Coyote Healing, Miracles in Native Medicine, and a number of other books. He’s a PhD and MD, Professor of Medicine at the University of Saskatchewan College of Medicine, and out on the East Coast practices at Beth Israel Medical Center. He’s also a practicing psychiatrist in Canada.

One thing I’ve noticed over the years is that, when we talk of Canadian medicine here in the United States, we don’t talk to Canadians (unless they are unhappy with that system). So we don’t get personal testimony about what single-payer means to ordinary Canucks. The following interview is limited, but does give some insight.

TH: You have practiced and taught medicine in the United States for the better part of a couple of decades …

LM: It’s been 32 years since I got my MD.

TH: …and you are now teaching and practicing medicine in Canada. Last night 60 Minutes did this amazing piece on a charity called Remote Area Medical that typically goes into third world countries or worse and sets up two and three day emergency medicine clinics for people who have never seen a doctor or are not going to have opportunity to see a doctor, and diagnostic and treatment facilities. And they did this in Knoxville, Tennessee, and people drove from hundreds of miles around and sat freezing in line all night long – they were absolutely overwhelmed. The state of American medical care for anyone who makes less than (fill in the blank) – somewhere between $40 and $70 thousand bucks a year, is not unlike that in a third world country. Or worse. And that’s not the case in Canada. Can you quickly describe for us what it is like in Canada? You teach there, you practice there, you are presumably a consumer of medical services in Canada. What is it like, and what would it take for the United States to make the transition into a Canadian-style system?

LM: Probably the simplest thing is that nobody worries about how we’re going to pay for anything, so as a patient you just go to the doctor and you don’t really worry about how much it costs. You just hand them your card and they bill for it and that’s that. And as a doctor, we’re not really worried about how you’re going to pay for it either. We just do what we think is best and that’s that. What’s amazing going to Canada from the U.S. is that no one ever asks what kind of insurance you have. No one ever questions whether or not you can pay for something. People get what they need. Yes, sometimes they wait for elective surgery, basically because there aren’t enough operating rooms, or sometimes it’s because there are not enough surgeons. But if it’s an emergency, it’s quick. There’s no such thing as what’s called utilization review. When I practiced in the U.S., someone from the U.R. department would come see me every day to try and kick people out of the hospital because they were costing money, or if I wanted to admit somebody to the hospital they would refuse.

TH: You see these shows like House, here in the United States, which is supposed to take place in Princeton Medical Center, and he says “Order an MRI and do a test for this”, and in reality, it would be “Would you please find if the insurance company will pay for an MRI?” It’s such a twisted view of medicine. What we’re seeing in our TV shows is medicine s it’s practiced in Canada or as it’s practiced in Europe, but they’re taking place in the United States. It’s bizarre.

LM: It is. You know, Canada has its problems – we still order too many lab tests, we spend less time with people that we should – it’s less severe than the United States, because in Canada as a family physician you can bill for every fifteen minutes that you spend with a patient, whereas here, as a family physician, you’re “tapped”, and so you can only bill for the first six minutes.

TH: After that the insurance companies won’t pay for it. That’s why the doctors try to get you out of the office as fast as they can, because after six minutes they’re not being paid anymore.

LM: So now, in Canada, if you see people very six minutes you can still make more money than if you see them every fifteen minutes. So, for instance, as a family physician, you would make about forty dollars for a fifteen minute office visit, but if you can do that in six minutes you still make forty dollars. Here you probably make about, I’m guessing, thirty dollars for an office visit, and so if you see them every six minutes you’re still making enough money to pay your overhead. But you can, in Canada, choose to see people every fifteen minutes, or you can see the same person for an hour …

TH And bill for four fifteen minute segments.

LM: That’s right.

TH: So then I can hear conservatives all over America screaming “Oh my God, people who just love to go to the doctor’s office are just going to come in and talk your ear off and I’m going to have to pay for it. It must cost a fortune!”

LM: Let me tell you about that. I’m using an American example, I have a friend in Scottsdale who has what’s called a “concierge’s practice”, and she’s a family physician, and she limits her practice to 250 people, and each of those people pay her $2,000 at the start of each year. They can come see her as much as they want. They can see her as long as they want. They never have to pay another penny. And what she found was that people see her a lot less than she wants them to when they can come as much as they want. And people get tired and they leave before she’s ready to stop the appointment.

TH: So the reality is that this whole myth of the people who want to take advantage of the system because it’s free is nonsense. There may be some small, one-thousandth of one percent of the people – the ones who are compulsive about having surgeries – there is a medical condition there you probably know the name of and I don’t. That’s the exception.

LM: Right. It’s really not a lot of fun to go to the doctor. … And every study that’s been done has shown that if you give people the time they need when they need it, they actually consume less resources over the course of a year. It costs you less to take care of people.

TH: Both because of preventive care and because people generally have better things to do than hang out at the doctor’s office.

LM: Right.

TH: And if the United States was to make this transition to a Canadian-style system, or more European style, a single-payer system, what is it that we would have to change, structurally or psychologically here in the United States in order for that to happen?

LM: People would have to change the idea that they deserve every test immediately, right now. A quick example, I know someone in Anchorage, Alaska, a 54 year old woman who smokes a couple cigarettes a day and doesn’t exercise, has high stress, had chest pain and went to the ER. The logical thing to do would be to make sure she’s not having a heart attack and schedule her for a stress test or a treadmill test where she walks on the treadmill …

TH: To make sure she’s not having a panic attack …

LM: Right. So what happened is she went straight to cardiac cath, a test that costs at least $20,000 …

TH: A cardiac cath is where they put the long tube in the femoral artery and snake it up into the heart and do this all under X rays. And this has a certain rate of death associated with it – nine out of a thousand?

LM: Not death, but some kind of stroke kills nine percent in one study [I think he meant to say that strokes are experienced by 9/10 of one percent of those who are subjected to this procedure.] So here’s a risky procedure that could have caused her many problems that cost $20,000, that really wasn’t necessary, and after she was done she was so grateful to them because they definitively proved that there was nothing wrong with her.

TH: Where instead of a $20,000 very dangerous procedure, they could have done a thirty dollar test – a blood test that would have shown that …

LM: Well, a treadmill test would probably be more like an $800 test, but if you pass your treadmill test, your chances of having a heart attack in the year are minimal.