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
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.
Family DoctorsThe 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
Mental Health CareAs 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.
Hospital CareTry 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.