The Best Medicine

A user's guide to getting the best health care the city has to offer, without blowing a gasket

Vincent Lam, Toronto Life
March 2006

here are good reasons why the health care system is now struggling to provide quality, cost-effective care: the boomers are aging, treatments are becoming more expensive and many medical areas are short-staffed. Of course, none of that matters when you're sick. When you're feeling lousy, all you care about is how to get the best care. The good news is that the system, for all its flaws and foibles, does have a lot to offer, especially in this city. You just have to know how to use it.

I'm an emergency physician at Toronto East General. Our ER sees more than 58,000 patients a year. Some leave disgruntled and offended, feeling they have not received the care they deserve, cursing the doctors, the system, the government. Others are amazed that a stranger had the grace and professionalism to help them in a profound way and feel grateful that they live in this city and country.

Patients tend to see their doctors as either demigods or charlatans. Truth is, we're neither. We're scientifically trained, mostly well-intentioned, perfectly flawed human beings. The most important thing I've learned about medicine is that the quality of the care and attention you get depends largely on the way you, your doctors, nurses and other health professionals interact. In a peculiarly Canadian way, the care you receive may be less about your station or wealth, and more a question of your interpersonal skills: cultivating respectful relationships with your health care providers. But to do that, you have to know how the system works. Here, an insider's guide to health care in Toronto.

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Family Doctors

The family doctor is the linchpin. He or she tracks your problem as it changes over the years, understands how various bodily systems affect each other, and is the point of entry and referral for every available health care service. The Canadian system hinges on family medicine. Our primary-care model is considered highly successful and is emulated around the world. To not have a family doctor in Toronto would be like living here without ever riding on a streetcar.

That said, Ontario—like the rest of Canada—has a shortage of family physicians. A wide gap between the income of family physicians and that of their specialist colleagues has made family medicine an unpopular choice among medical students. The Ontario Medical Association estimates that 1.2 million Ontarians don't have a family doctor, and the number is growing. At social gatherings, when people find out I'm in medicine, one of the first questions they ask is, "Do you know any family doctors who are taking new patients?" Here's what I tell them.

How to Find One
First, ask your relatives about their doctors. Do it before you get sick, because it might take time to wheedle an appointment. If your sister has a doctor she loves, and you call, the receptionist may tell you that the practice is closed to new patients. However, many family doctors who are officially closed will still take people who are relatives of existing patients, particularly if they're in the same household. Ask. Better yet, have your family member ask when they are in for their next appointment. You can ask your friends for recommendations, too, but that route can take longer. If your friend loves her doctor, ask her to plead your case, stressing what a lovely person you are. But what really matters is your friend. If she is nice and keeps her appointments, the doctor is likely to assume that you'll act the same way.

OK, so you've called 10 recommended doctors, and no luck. Try the Web site of the College of Physicians & Surgeons of Ontario, where you can search for a family doctor by community or by postal code. If you're in central Toronto, try the hospital family medicine clinics—essentially doctor's offices in hospitals—at the city's large teaching institutions (such as St. Michael's Hospital, Mount Sinai, Sunnybrook and Women's College Health Sciences Centre), where family medicine residents are trained for two years. Under the supervision of a staff physician, they often run a practice within their training program, which is, by definition, new and open. If you're happy with the resident, ask where she plans to set up a permanent practice.

July is a good month to start your search. This is when new graduates come out of residency. Some will join existing practices, so inquire at clinics that previously told you they were closed to new patients. Also, the summer is often a slower time in most doctor's offices, which could increase your chances.

What You Should Look For
Get a family doctor who is close to either your home or your work. Think about what time of day you're most likely to want to see your doctor, and whether the doctor's location and appointment time slots fit into your schedule. A crucial determinant of the quality of your health care will be how easily you can see your doctor when you need to. Also, if your family doctor has her practice near your work, and you want to see her on short notice but she's booked solid, the receptionist might be willing to phone you if there's a cancellation or no-show. Or, if the clinic is running hours behind, the receptionist might let you sneak back to your office, and then phone you when your appointment is coming up.

Remember, too, that doctors are somewhat neighbourhood based. They refer their patients to specialists in the area, and send their patients for tests at nearby hospitals. It may be tolerable to travel across town once a year for a checkup with a doctor who is perfect for you, but if you get sick and need to see three specialists in a week, all of whom are on the other side of the city, it will become inconvenient.

How They Are Paid (And Why You Should Care)
The landscape of family medicine payment is changing, but most doctors are still paid on what is called a "fee for service" system. Implicitly or explicitly, family doctors often limit you to one problem per visit. The reason is simple: the amount that your family doctor can bill the government for a typical visit—which in most offices runs between 10 and 12 minutes from hello to goodbye—is $29.70, which has to cover rent, equipment, insurance, professional expenses and nurse and receptionist salaries—all before the doctor's cut. Given that overheads run at about 40 per cent, your doctor is probably making $17.82 for seeing you. (In some cases, it's even less: you want a bandage after your flu shot? It comes out of the $8.65 your family doctor gets from the government per injection.) The overhead costs are still ticking even when your scheduled appointment time is over, so if you feel like your doctor is eyeing the clock, he probably is.

Since 10 to 12 minutes is pretty much the minimum time it takes to properly assess any single problem, give you an educated opinion about it and formulate a treatment plan, don't be surprised if your doctor looks displeased when you take out a list of seven health issues to cover in one appointment. Do everyone a favour, and book a separate appointment for each separate issue. Even though it involves more schlepping, it won't cost you a cent and your doctor can bill an A007 (the billing code for a typical visit) every time you show up. This isn't as crazy as it sounds: two separate visits truly is more valuable to you than a single rushed one.

Also, don't call. The health care payment system is predicated on the patient being in the exam room. The doctor is paid zilch to answer calls for advice, fax sick notes and write prescriptions—which can rarely be done responsibly without a face-to-face clinical encounter. Your family doctor may grudgingly do these things while mumbling that you should really come in to the clinic, but remember that no one works especially well for free.

Because your doctor doesn't get paid if you don't show up, there's no better way to earn his animosity than to miss appointments. Cancelling without at least a couple of days' notice is equally irksome. Some offices will charge you for the cost of a visit even if you don't show up. If you are asked, don't even dream of arguing about it. Just apologize and pay (a note of apology along with a cheque for $29.70 would be met with astonished gratitude).

But your doctor always runs late, you say, and you're not reimbursed for your lost hours in the waiting room. The truth is that excellent doctors sometimes run late because they take the time to address a problem even if there wasn't enough time allotted for it. If you insist on a doctor who is always on time, you'll end up being rushed out on the days you really need those few extra minutes.

How to Get the Best Care
Be honest about your health problems, take responsibility for addressing them, and follow through with what the two of you agree you will do. Make sure that the first thing that comes out of your mouth is the most important problem of that day. Spend five minutes before every medical appointment asking your-self about the one important thing that you want to learn or achieve. Ask yourself, "What is it about this symptom that is really troubling me?" and "What do I want to come away from here with?" Having a smaller number of problems to address means that their assessment and management will be much more meaningful.

Stories are compelling. Tell your story poorly and you'll end up with a random series of stabs in the dark—tests ordered in order to "cover the bases," treatments prescribed without a clear end point but because "it might help, and it probably won't hurt." Try to explain what you are experiencing in a sequential way that forms a narrative. Before you see your doctor, be able to answer these four questions:
1) Location: Where does it hurt, or where has it been bothering you? Know the location well enough to be able to point to it with one finger. (Don't demonstrate by grabbing or poking the nurse's or doctor's body—this is a surprisingly common move, and high on our list of pet peeves.)
2) Description: Use plain English. Focus on specific symptoms, and forget about what you think the undiagnosed problem might be. In trying to make a case for a particular condition, you lose the benefit of a fresh, unbiased medical opinion.
3) Duration: How long has it been bothering you, and is it constant or intermittent? Many treatments, such as the one for heart attacks, depend upon the timing of a patient's symptoms. Be able to say if the problem has been there for minutes, hours, days or weeks.
4) Intensity: The best way to describe how intense something was is to say how it affected what you were doing. For example, say if the pain was so severe that you had to pull your car to the side of the road and stop driving, or if you've been too nauseated to eat solid food for two days.

Manage Your Own Information
Information technology in health care changes slowly, hampered by the layering of multiple systems, and by the issue of the privacy of medical information. In Ontario, our health information systems are shockingly archaic. Many are unreliably paper-based (think telephone book-size charts with no index or organizational principle whatsoever). Other hospital and clinic information systems are electronic and incompatible with each other.

If you have a complex medical history, manage your own health information. Request and keep copies of your lab tests, electrocardiograms, ultrasounds, X-rays and consultation reports. The changes seen on sequential tests are generally more revealing than the information from one test alone. Have a master copy at home, then have a photocopy in your file ready to grab on your way out the door should some medical emergency occur. When you are going to see a new doctor, bring a copy that he can add to his records. Never assume that the file has been transferred or that a clinic can call in the chart, because half the time the file never makes it, or it has been lost.

If you're seeing a new specialist or going to the ER, ask your regular doctor which summaries are most relevant to bring with you. It's best to bring two copies. Give one copy to care providers, and keep another as backup.

How to Find a Doctor For Your Child
Many pediatricians in Toronto are shutting down their offices and entering into a more consultative or hospital-based prac-tice. Kids with recurrent health problems might still need a pediatrician, but most healthy kids will be well served by a family doctor—providing you find a kid-friendly one. Ask your family doctor whether she sees a lot of kids. If you bring your baby in for a checkup and your doctor asks about sleep-related issues, that's a good sign that she's tuned in to what babies are about. Also, if she delivers babies, she is probably comfortable treating kids. But more important, observe how she interacts with your child. You'll know.

It's good to evaluate the child-doctor relationship when the child is not acutely ill and in pain, when there are no immunizations or other "ouches" involved. If your child is already school age, ask him if he likes the doctor, since for kids, liking someone is wrapped up with the ability to communicate with them and to trust them.

Adolescence is the time to think about whether your child should have a different doctor than you. Assess whether your adolescent seems to be able to communicate well with the doctor, not whether the doctor tells you what you want to know about your teen. Your teen's ability to speak openly and honestly with his doctor about emotions, sex and street drugs is critical. Although any doctor is bound by relationships of confidentiality, some teens may not want to ask the same person who does Mom's pap smears or Dad's stress tests about the dangers of crystal meth or getting a prescription for the pill.

For a wide range of health information about babies and children, try the Canadian Paediatric Society.

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New Forms of Traditional Family Practices

The Ontario government has pilot-tested several new systems in the last few years and is hoping to promote them across the province. They're all variations on a theme whereby family doctors are paid for providing services that they've traditionally performed for free, or for very little or not at all. The hope is to alleviate the growing family physician shortage: to encourage family doctors to do good work and to make it more attractive for newly trained doctors to choose family medicine as their specialty.

Family Health Groups and the Comprehensive Care Model
The FHGs and CCMs are regular doctor's offices that offer a few extra perks. They're still essentially fee-for-service systems, but they kick in a few bucks to the doctor for working evening hours, for offering emergency after-hours advice on the telephone, for undertaking preventive health activities (such as helping patients stop smoking and screening for colon cancer) and for taking care of difficult and complex patients (whereas walk-in clinics thrive on the easy in-out business). FHGs and CCMs make it possible for you to get evening health care from your doctor (or one of their group members), and telephone access is a bonus (you can call to determine, say, whether or not your problem is severe enough to warrant a trip to the ER). If this system appeals to you, ask your doctor if she participates in the program.

Family Health Networks
In the FHN system, your family doctor would get a flat annual fee of $107.28 for caring for you—before subtracting overhead, of course. (If you have complex medical conditions like diabetes, your doctor will get roughly $60 more annually.) This works nicely for the doctor, if you don't make loads of appointments. He may even be happy to help you out once in a while over the telephone. But if you show up every week for six months to ask about something you read on the Internet when there's nothing medically wrong with you, you may find that your doctor's bedside manner isn't as friendly as usual. If this system appeals to you, ask your doctor how his practice is set up.

Community Health Centres CHCs were created to provide patients with comprehensive primary health care and to customize health and social services to best serve specific populations. For example, the Shout clinic at Jarvis and Maitland is reserved for youth at risk, while the Queen West CHC at Bathurst devotes a chunk of its resources to the health of the homeless. Here's how they work: the provincial government pays the rent and the hydro, and gives the doctors, nurses and all other staff either a salary or an hourly wage. That means doctors won't be financially penalized for spending extra time with you. Visits tend to be longer than those with a typical family doctor, but as fewer patients are seen by a CHC doctor on any given day, there are also fewer appointment slots available—and in some cases you might be turned away if you don't fit the target demographic. There are now a total of 22 CHCs operating in the GTA. You can find a listing of them on the Web site of the Association of Ontario Health Centres

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Mental Health Care

As with all things medical, your family doctor is a good place to start. She may be able to steer you through a range of options, including specialist psychiatrists, psychologists, social workers, workplace employee assistance programs, counsellors and family physician psychotherapists. (The non-physician professionals are generally only covered by OHIP if they are working in affiliation with hospitals.) If at first you don't identify with your new psychotherapist or psychiatrist, go at least three times before you bail. One visit isn't sufficient to determine if it's a good fit. Besides, it will be hard to get your family doctor to send you to someone else if you haven't given the first one a fair shake.

Family Physician Psychotherapists
One of the most accessible options for mood and anxiety issues will be a family physician psychotherapist. There is a network of family physicians who have additional training in psychotherapy, and these physicians are typically more readily available than psychiatrists. Some do psychotherapy for their own family practice patients, as well as for patients referred from other doctors, and some do exclusively psychotherapy. For more resources, check the Mental Health Service Information Ontario.

How to Get Mental Health Care For Someone Else
Family members sometimes need to bring their mentally ill, and unwilling, loved ones to the hospital. If it's an immediately dangerous situation, 911 will bring the police into play. There are also about three mobile crisis units: roving counsellors and conflict mediators for those times when a 911 call seems extreme.

If a family member is suicidal, wants to hurt someone else, or is unable to care for himself and physical harm is imminent, you can go to court, appear before a justice of the peace and fill out an application for a Form 2, which mandates that the police bring the patient to the hospital for an examination. A physician will examine a patient to determine if he might be a risk to himself or to someone else, in which case he'll place a patient on a Form 1, which leads to a compulsory stay for psychiatric evaluation. From that point on, all the mechanisms mandating involuntary stays in hospital are a delicate balance between the patient's freedoms and rights, and the danger he presents to himself or others.

Ask the hospital or psychiatrist about getting a case manager, a non-medical person who is typically affiliated with either a hospital or community agency. A case manager can help people with mental health issues get to their appointments, fill prescriptions and do other practical day-to-day things. Also, ask about family support programs, which most hospitals offer to help families deal with a mentally ill loved one.

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Hospital Care

Try to establish a "home" hospital. The best hospital for you will likely be one that has connections to your family doctor and any specialists who might be involved in your regular care. If you have already had your condition treated at one hospital, try to go back for subsequent problems, especially for any complications arising after a surgery. Once your operating surgeon has done her work, you are considered her patient until that problem is sorted out. No one knows what happened during the operation as intimately as the surgeon who performed it, and if there are problems, no one else will want to clean up the mess. (Of course, all bets are off when it's an emergency—you should just head for the nearest hospital.)

Should I Call an Ambulance?
If you can't get to the hospital by yourself or if you need immediate attention, call an ambulance. But understand how it works: ambulances in Toronto are controlled by a central dispatching service that directs them, based on the severity of the patient's needs, to hospitals where there are ER beds and the appropriate resources. In other words, they won't go where there's already a parking lot full of marooned ambulances. So using the ambulance system may result in your not going to the hospital you prefer. If it's safe, transporting yourself gives you more freedom of choice.

Why Visiting Hours Matter
If you have a family member admitted to hospital who cannot speak or com- municate, visit often, and ideally during the day. You'll learn about treatments and gain insight into your family member's situation. Even if they don't ask a single question, the presence of family and visitors changes the atmosphere that surrounds a patient. It may seem like no one is paying attention to you, but the staff know which patients have lots of visitors and which do not. An internal medicine ward nurse once told me, "In theory, everyone receives the same quality of care, but we know which patients have lots of visitors, and you'd prefer for those patients to look good and feel good as much as possible. The families whose patients get the best care are those who ask questions, but not so many that we get annoyed. You just want to make them happy."

A Day in the Life of a Hospital (And Why You Chould Care)
In rough terms, the daily cycle of the wards is like this: the morning is a kind of crossroads, where staff figure out what direction people are heading and how to get them there. Patients are reassessed and moved to the next step of their care: they may receive further tests or treatments, or get transferred to nursing homes or discharged. Surgeons typically check in on their patients early in the morning, often before most of the city has woken up.

For the rest of the day, plans conceived in the morning are played out. Patients go for tests, surgeons operate, treatments are administered and test results appear. Your chances of getting someone to give you a thoughtful, well-considered explanation or diagnosis are better in the morning and early afternoon.

As in any workplace, as the afternoon goes by, things become more hectic. Doctors try to tie up loose ends, finish paperwork, chase down test results and leave for home. If you attempt to corner your family member's attending physician at the end of the day, when he has to pick up his child from daycare, you'll probably get rushed answers to your questions.

After-hours and overnight, the hospital is still running, but big-picture decisions about treatment direction and comprehensive consideration of the patient's situation are generally put off until the next day. Patients are monitored, and if something goes wrong, the nurses are there to respond to the problem. If necessary, the on-call doctor is consulted. In the downtown teaching hospitals, wards are usually covered by a team of residents who are working long shifts. A number of studies have suggested that the highest rate of errors by hospital staff occur early in the morning, between about 4 and 6 a.m. So, be sure to take anything you hear at that time of the morning with a grain of salt. The doctors and nurses are doing their best; it's just that their brains aren't operating on all cylinders. To be safe, write down what you are told and what decisions are made at night. Later that morning, go through it again with a doctor who has had a full night of sleep.

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Specialists

One of the problems with the health care system is that simple issues can be treated quickly (if you have a little cut, it will be sewn up the same day), and critically ill people can be treated quickly (if you are having a heart attack, you will receive excellent critical care in minutes), but moderately ill people with long-standing, chronic, complex issues sometimes have to wait a long time for a resolution. If you have a problem that doesn't threaten your life but is making you miserable, the system moves slowly. Getting consultations with specialists can take weeks or months and is often a source of frustration. Here's how to make the best of it.

How to Get An Appointment With a Specialist
Don't call your family doctor and ask for a referral over the phone. Even if he agrees, it won't result in a meaningful assessment of your problem or a quality referral. Make an appointment so your doctor can examine you. Listen to what he recommends, and try it. You may not need to see a specialist at all.

Should your problem persist, go back to your family doctor. A second or even third visit is sometimes critical to making a smart referral. If you're worried about how long you'll have to wait to see a specialist, ask if there's a treatment you can start in the interim. If you're really sick, most family doctors will try to speed things up.

If you're thinking of asking your doctor to help you jump the queue, understand what's involved. Because the consultant's office dictates the timing of appointments, your family doctor will have to cajole the specialist. It often requires justifications and the calling in of favours. Don't be surprised if your doctor decides against making the effort, even if you ask really nicely: attempting to bump up someone who is non-urgent impairs your family doctor's credibility in the eyes of the specialist and later will make it difficult to get appointments for the people who really need speedy attention.

You want to see a particular specialist that your cousin's plumber says is amazing? Sure, ask your doctor to refer you. They probably will. But you might not be getting the best possible care. Your doctor has relationships with certain specialists who in turn rely on your family doctor for business. And as in every other walk of life, relationships matter. When a specialist receives a call from a physician who routinely sends him business, he's more likely predisposed to be helpful.

How to Get the Most Out of Your Specialist
It's important you understand why you are being sent. The three main reasons for consultations are diagnosis, treatment or procedural testing. If you have a strange rash, you may be sent to someone to figure out what the heck it is. If you have bad arthritis, you may be sent to an orthopedic surgeon to decide on a joint replacement. If you have a family history of bowel cancer, you may be sent for a colonoscopy. If you are not sure why you're being sent to a specialist, ask your family doctor. You have a better chance of getting something useful out of the interaction if you know why you're there.

Most specialists make much more money the first time they see you, and earn about the same as a family doctor for follow-up visits. So, try to make the most of the first appointment and leave having advanced your situation, because you become less financially worthwhile in subsequent visits. Also, before you leave your appointment, clarify with the specialist whether she will be initiating and following your treatment or sending you back to your family doctor for follow-up.

If the specialist recommends a treatment—a joint replacement or a cancer treatment—and you're curious about the waiting times for hospital procedures, check out The Ontario Ministry of Health and Long Term Care.