Method
The study was conducted using Survey Monkey, an online survey engine. The respondents were a self-selected sample of Facebook users. There were 32 usable responses. No demographic data was collected.
The population size was taken to be 1262, the average number of votes cast for mayor in the last three elections (2003, 2006, 2009). The 2007 by-election was not used as MACA could not make the numbers available.
The purpose of this survey was to study how public opinion could be reconciled to the realities of medical staffing in Hay River.
Use of medical services
The first step was to determine why clients use medical services in Hay River. The respondents were asked how many times a year they use medical services in Hay River, and for what reasons. The answers were as follows:
| Frequency | Percentage |
| Less than once a year | 6 |
| About once a year | 22 |
| Two to four times a year | 28 |
| More than four times a year | 44 |
The reasons for using medical services were as follows:
| Reason | Percentage |
| Prescription rewrites | 53 |
| Acute but non-emergent condition | 44 |
| Annual physical exam | 38 |
| Medical emergency | 34 |
| Routine pediatric ("well child") exam | 31 |
| Chronic condition | 25 |
| Pregnancy | 22 |
| None of the above | 6 |
Interestingly, one respondent reported using medical services more than four times a year for "none of the above". Note that these are the percentage of patients using medical services for a given reason, not the percentage of visits for a given reason.
The important demographic here is patients with chronic conditions, because they are the only ones for which studies show a clear benefit from continuity of care, in the form of fewer emergency room visits or hospitalizations (1). For the rest, continuity of care
may increase patient satisfaction, but studies are not unanimous on this.
This survey may underestimate the number of patients with chronic conditions in Hay River, as many are older and therefore less likely to be filling out Facebook surveys.
Client attitudes to permanent doctors
This aspect was measured using a five-point Likert-type scale. The items were as follows:
- Everyone needs a family doctor.
- Seeing the same doctor every time improves health outcomes.
- Nurse practitioners provide the same quality of care as doctors for many conditions.
- Only certain procedures need to be performed by a doctor.
- Many chronic conditions can be monitored by the patient or regular caregiver.
- People should take more responsibility for their own health.
The responses were as follows (click for a bigger version):
Because the point is to study how easily clients can be weaned off the permanent-doctor concept, the first two points were scored backwards, from 5 to 1 instead of 1 to 5. The outcome is then as follows:
Interestingly, the respondents are well aware that we can very well do without doctors most of the time, but still maintain that we all need doctors. The idea that "everyone needs a family doctor", though pushed heavily by the College of Family Physicians of Canada (obviously a group with an agenda), holds no water. Healthy people don't need doctors at all, and most respondents did not even use the services where a family doctor might be a worthwhile concept, namely routine physicals. Only 38% of respondents went for annual physicals, and 31% for routine pediatric exams.
The main advantages of having a family physician are in both client satisfaction and the physician's job satisfaction. But of course this is only the case for clients who
want a family physician and find one they like. Many clients really couldn't care less who they see, as long as he does a good job. According to the College of Family Physicians of Canada (2):
- About 80% of Canadians reported they preferred to access care through their family
physicians.
- About 88% agree that having a family doctor allows them to feel more confident about access to other services.
- More than 80% of Canadians rate the quality of care of family physicians as good to excellent.
- More than 66% identify family physicians as the most important caregivers for them and their families.
That is to say, between 20% and 33% of Canadians
don't prefer to use family doctors, and 20%
don't find family physicians "good to excellent." In addition, the research methodology behind these findings (including the wording of questions) may have introduced a bias towards family physicians. In any case, this is certainly a good ways from "everyone needs a family doctor."
As for "seeing the same doctor every time improves health outcomes", Cabana and Jee point out that holding out to see the same doctor leads to delays in obtaining medical care for acute or emergent conditions, thus possibly
worsening health outcomes; that a second opinion is often beneficial in "avoiding incorrect or delayed diagnoses"; and that "providers with different expertise may be able to complement each other's expertise and thus provide better services overall". Not mentioned is the obvious fact that many conditions, such as cancer, diabetes, multiple sclerosis, autism and many more, are treated by specialists, not by family physicians.
I then separated the answers to the Likert-type scale between patients with and without chronic conditions, thusly:
Not surprisingly, patients with chronic conditions are more attached to continuity of care – as they should. What's interesting is that they are
less likely to agree that chronic conditions can be monitored at home, or that people should take more responsibility for their own health. I had expected them to be better informed than those without chronic conditions, but perhaps what's more logical is some of them might not have chronic conditions if they had taken more responsibility for their own health. So rather than showing chronic patients develop a poor attitude to personal responsibility, it might show that people with a poor attitude to personal responsibility are more likely to develop chronic conditions. (Ok: duh.)
Clients' willingness to pursue continuity of care
One study on patient attitudes toward continuity of care found that while patients generally claim that continuity of care is important to them, few are prepared to put themselves to any inconvenience to maintain it. (3) This survey found the same.
This doesn't need much comment. There was likewise little support for the idea of cutting other municipal services to pay for doctors. Just to have something to say, I took the mid-point of each interval, weighted by the percentage of respondents choosing that interval, and multiplied by the number of occupied private dwellings (1405 according to Statscan), and thus calculated that the town
might be willing to spend some $280,000 more on attracting permanent doctors. It wouldn't help. In 2008, the town had brought in a consultant to discover why, exactly, we can't get any permanent doctors. The usual answers involved money or hours of work; the consultant found that in reality it is the social setting that is unappealing. There are no similarly-educated people with whom to socialise, no interesting cultural events, no academic or extra-curricular opportunities for their children, and so on. Of course since no one may say anything that doesn't make people happy, this doesn't seem to have been reported on, ever. The only reason I know about it is that I got to drive the consultant to the airport on his way out. There is however a certain recognition of this in the town. The Likert item "the town's social and cultural climate is attractive to medical professionals" scored only 2.63, on the disagreeing side of "no opinion".
On the other hand, $280,000 could most likely hire care coordinator to improve the continuity of care and give the clients the impression someone cares (somewhat lacking in the current system).
Likewise on the question of travel:
Just as Pereira and Pearson found, the majority of patients wouldn't actually bother to travel to see a preferred physician. In this case however, the attitude is influenced by the fact that respondents feel entitled to have the government provide their choice of physician in Hay River. This of course ignores the economic reality that the cost of healthcare is outpacing governments' ability to fund it throughout the world, and the professional reality that most health care functions don't need to be performed by doctors (see
Squeezing out the doctor,
The Economist, June 2012).
What's funny is the response to the question, "Permanent doctors means having to see the same doctor every time whether you like him or not. Is this trade-off acceptable?"
Considering that the main benefit of continuity of care is found to be patient satisfaction, this is humorous. It would be interesting to be able to send the respondents to some useless quack a few times and see whether they claim to be more satisfied with him than with the current situation. As in anything else, about half of all doctors are below-average at their job, so being able to see the same one every time is only likely to be satisfactory if the patient can choose the doctor. In our case, where we would be stuck with whoever chooses to come here (not very likely to be a top-flight practitioner), it's very unlikely that satisfaction would be much improved in the long run, though there might be a temporary surge in reported happiness from people who got what they wanted. It would probably be equally pointless to explain that continuity of care can be provided within the current organisation without the patient having to see the same practitioner every time.
Ultimately this survey shows mostly that the respondents' attitude towards permanent doctors is firmly entrenched in unjustified assumptions, and therefore will be very difficult to reconcile to reality. Moreover, the public is holding the municipal government responsible for this situation, when there is really nothing any level of government is likely to be able to do about it. It's difficult at this point to make any suggestion to municipal candidates on how to handle this issue.
Client attitudes to midwives
The average response to this question was 3.50, vaguely on the side of agreeing. In reality it is odd that anyone would have an opinion one way or the other because the answer is completely dependent on the specific pregnancy. A high-risk pregnancy should certainly not be handled by a midwife in Hay River, and for that matter no midwife would take it on. For the rest, most women have a preference between different styles of delivery. Again, having one or the other available in Hay River would reduce the women's choices.
Using the same method as for doctors, this yields an approximate $170,509 in extra taxes to pay for midwives. In this case, the number is of some relevance, since midwives could indeed be persuaded to settle in Hay River, but the territorial government is probably not about to devote money to such a project. $170,509 is unlikely to pay for a permanent midwife, but perhaps a deal could be struck with the GNWT, if the town actually decided to put up this money. It might be worth mentioning, anyway.
Chilling callousness
I'd like to hope that those who would dispense with long-term care simply don't know anyone who lives in a facility. Or, perhaps they reasoned that we don't have to sacrifice all of long-term care to get midwives here (wherein they may be right) and that by voting for birth services they're gaining one without losing the other. The reality is however, that spending a month out of town really is just an inconvenience. There is an emotional impact to being away from family at a time when hormones push for greater connectedness with loved ones, but the effect on health outcomes, if any, has not so far reached news-worthy levels. On the other hand, people who are compelled to live in long-term care facilities by definition have serious health concerns to begin with, and are very often vulnerable to abuse and/or unable to advocate for themselves. Some may spend decades in such facilities. Contact with and support from loved ones is not only of practical relevance but also medically important, as it improves morale and has a documented positive effect on the clients' strength and health. (Your correspondent doesn't have a study handy, but just google "twins in incubator" and you'll probably find support for this.) As long-term care beds are in very short supply in the territory, cutting those in Hay River would move some long-term patients out of the territory. Either the health effects for them would be significant, or their families would follow them, which might then improve their outcomes, but would be rather contrary to the economic goal of increasing the town and the territory's populations.
Nothing to do with health care
The average vote was 6.8 councillors. The problem with having only six councillors, however, is the amount of attrition and absenteeism in council. In the current term, one councillor quit, one became mayor when the mayor quit, one hardly ever has anything to say, and three seem to be absent a lot. Going down to six councillors wouldn't necessarily weed out the worst two (check out the 2007 by-election results), but could make it difficult to get a quorum.
1:
Does continuity of care improve patient outcomes?, Michael D. Cabana, MD, MPH and Sandra H. Jee, MD, MPH; December 2004
2:
Family Medicine in Canada: Vision for the Future, The College of Family Physicians of Canada; November 2004
3:
Patient Attitudes Toward Continuity of Care, Anne G. Pereira, MD, MPH and Steven D. Pearson, MD, MSc; April 2003
