THE FUTURE OF CANADIAN MEDICAL CARE IN 2050

The following passage describes a hypothetical transcript of a conversation in the year 2050. This is between a patient Dr Jones (a retired doctor) and his grandson Care Consultant Jones, a doctor of the future. It outlines several possible changes that could take place in Canadian medical care in the next 40 years.

Care Consultant Jones: Good morning grandfather. I have washed my hands in the cleansing pod [1]. The entry button should be flashing so you can let me in.

Dr Jones: (searches around frantically) Found it! (Care Consultant Jones enters the room) I sometimes despair at all this new technology, I’ll never get used to it Roger. In my day, we just trusted people would have the common sense to wash their hands. Last week, I heard there was a gentleman in ward 15 whose cleansing pod broke. He was stuck in his room for days!

Care Consultant Jones: That’s just a malicious rumour. The engineers from Biotech corp [2] would never let that happen. Who would want to book into this hospital if that were true? [3]

Dr Jones: When I was a doctor, nobody was able to choose which hospital they went to. We all foolishly assumed that all hospitals tried their best! All this talk about the Biotech corp engineers just reminded me about my broken plasma screen. Could you ask the health care assistants to report it to them for me?

Care Consultant Jones: There will probably be several forms to fill in. Biotech corp is notorious for their
paperwork. In one ward round, I have to file at least 100 different electronic forms on my PDA. It is all because Biotech corp is so afraid of litigation. The amount of time I spend on documentation for a patient is ridiculous.

Dr Jones: Remember that you are very fortunate to be able to use PDAs [4] . We had to write down everything by hand!

Care Consultant Jones: I don’t understand how you can practice medicine without a PDA. How would you know a patient’s history when they came into the hospital?

Dr Jones: We used to take the history from the beginning every time a patient came into the hospital. The whole process was a good learning exercise for the medical students.

Care Consultant Jones: My medical students would definitely not be happy if I asked them to take everyone’s histories without a PDA. They would probably sue me for not providing a proper education [5].

Dr Jones: The amount of litigation has spiralled out of control! First the patients are suing their doctors and now the medical students are doing the same. Your insurance premiums must be extremely high [6].

Care Consultant Jones: I am just lucky that Angela is a lawyer. We would not be able to survive on my wage alone especially after I have paid the medical insurance premium.

Dr Jones: How are Angela and the children?

Care Consultant Jones: They are all fine. Johnny is now in his final year of medical school.

Dr Jones: Has it been 4 years already?

Care Consultant Jones: Medicine only takes two years now. Only graduates from the new pre-med courses can apply and they just do the clinical clerkships [7].

Dr Jones: Do they not learn about anatomy?

Care Consultant Jones: I think they only do virtual surgical anatomy. I was asked to teach it but I already had enough teaching points to fulfil my contract [8].

Dr Jones: Will Johnny be starting as a resident soon?

Care Consultant Jones: I think his official title is a F.C.A. It stands for Foundation Care Assistant.

Dr Jones: He will be very busy. I remember when I was a resident, I never had enough time for lunch.

Care Consultant Jones: He told me his shifts are scheduled for 9am to 3pm everyday for the first two months of the rotation. There are so many students graduating from medical school now that they have too many FCAs [9]. They all only work a few hours each day.

Dr Jones: How can they possibly attain the experience needed to be a doctor in that short time?

Care Consultant Jones: It’s generally expected that they can’t get the necessary experience. However, the rest of the time is set aside for formal teaching and other methods of training.

Dr Jones: Do they get paid for that?

Care Consultant Jones: No, it is terrible that they do not get paid but they have to take part. They have an obligation to teach the medical students. Otherwise, Biotech corp will terminate their contracts. They also have an obligation to receive a certain number of training points otherwise, their insurance premium is invalid.

Dr Jones: How will he survive?

Care Consultant Jones: We said we could help him out financially but he might have to get a part time job.

Dr Jones: Who would have thought that one day doctors would need to take a second job? We always used to moan about our pay as a resident! At least he’ll become an attending quicker under the new system. Does the pay go up then?

Care Consultant Jones: Yes it does but then so do the insurance premiums!

Dr Jones: What does he want to specialise in?

Care Consultant Jones: He doesn’t have to choose at the moment. He automatically becomes a general attending physician after five years, providing he passes all his competency assessments. After that, he is expected to work as a general attending physician in the hospital at night scheme for at least two years until he can specialise to become a care consultant.

Dr Jones: They make him work night shifts for 2 years?

Care Consultant Jones: It’s the only way that the hospitals can stay open for 24 hours a day. Patients won’t be kept waiting for anything nowadays, especially since they all pay the health tax [10].

Dr Jones: It was lucky that I retired before the health tax came into effect.

Care Consultant Jones: It should have been reduced when the Biotech companies started to run the hospitals [11]. However, the government claimed that costs had risen so much that a health tax cut would have been the end of Medicare.

Dr Jones: That argument is an old excuse. It’s not really a government funded Medicare system anyway. As far as I can see, we pay for the privilege of going into the hospitals and the Biotech companies take away all the profit from running them.

Care Consultant Jones: All these extra taxes will be the cause of my financial ruin!

Dr Jones: I suppose that I should count myself lucky that I still receive a government pension [12].

Care Consultant Jones: Biotech corp has decided that they couldn’t possibly provide a pension for their Medicare employees. All the money that they have made from their new drugs must be used to pay for their extensive research and development programs.

Dr Jones: That argument is also an old excuse. I hope you are not put under any influence to prescribe these new drugs. Are you?

Care Consultant Jones: I can prescribe any medication available. However, the hospital only stocks Biotech corp drugs. So if I wanted to get something from a rival firm, it would take 5 days, and I would have to fill out about 5 forms.

Dr Jones: That’s disgraceful! I’m surprised that no one saw the conflict of interest.

Care Consultant Jones: The Biotech lobbies are so large in this country that nobody can argue with them. Anyhow, I hardly have to prescribe anything nowadays.

Dr Jones: I believe the new term is nursing prescribing power! [13] What precisely do you do at work Roger?

Care Consultant Jones: As far as I can figure out, we basically just keep an eye on things. The nurses prescribe and follow the care pathways. We are just there to check that everything is running smoothly.

Dr Jones: That means that no independent thought goes into the process! These care pathways are a menace. My doctor refuses to deviate from it even though I show him evidence from the latest clinical trials.

Care Consultant Jones: Patients are always showing us their internet derived evidence. It’s an unfortunate situation but we open ourselves to litigation if we deviate from the care pathway. Our insurance also becomes invalid. They are theoretically evidence based and updated automatically onto our PDAs.

Dr Jones: Theoretically is the correct descriptive term. What if I don’t agree with the interpretation of the evidence? Also, we all know that the Biotech lobby influence the people who review this evidence [14].

Care Consultant Jones: The nurses claim that the care pathways help them provide a standardised care to all the patients. We all know how powerful the nursing unions have become.

Dr Jones: As far as I can see the nurses do all the things that I used to do as a doctor. They prescribe drugs and look after the patient from a medical point of view. My nurse has called for the doctor’s advice only once since I have been here.

Care Consultant Jones: That doesn’t surprise me. We are just there as a final check on the process. They see the patient, bring up the history, follow the care pathway and institute the evidence-based management. The nurses hardly call me.

Dr Jones: I heard a rumour that the nurses get paid more than the junior residents now.

Care Consultant Jones: That’s not technically true. They get paid a slightly lower hourly rate than the FCAs, but they do more hours and so get paid a larger annual income.

Dr Jones: That’s how the idea was sold to the Canadian Medical Association!

Care Consultant Jones: The CMA has very little power compared to the nursing unions. If the doctors went on strike the hospitals would still be able to function but if the nurses did the same then the whole place would grind to a halt [15].

Dr Jones: I suppose if the nurses do all the work they should get paid more.

Care Consultant Jones: The nurses and the Family Practitioners get all the money.

Dr Jones: My Family Practitioner just bought a new Porche. Is it true they get paid per procedure and not by patient now?

Care Consultant Jones: There would not be much point in paying them per patient. They all have these super-clinics with thousands of patients in them. They get paid standard fees for the annual check-up, minor operations and specialist health checks.

Dr Jones: There is a big difference between what you would call a minor operation and what I used to call a minor operation. In my day, the general surgeons still did hernia repairs.

Care Consultant Jones: The Family Practitioners do almost all the operations now. Our attending general surgeons in the hospital only do organ transplants. Any pathology is treated with an organ transplant.

Dr Jones: We used to have a shortage of organs.

Care Consultant Jones: Donation was always a terrible way to obtain organs. We are fortunate that the government decided to ignore the protestors and grant the Stem Cell Research Bill [16] and now we can grow any organ we need in the laboratory.

Dr Jones: I am sure that Biotech corp would have used any means necessary to be able to grow organs in their laboratories. They must sell the organs to their own hospitals for a significant profit.

Care Consultant Jones: We should try to be a little less cynical next time I visit. I should go home. I have to get ready for my re-registration exam with the Provincial Medical Licensing Board [17].

Dr Jones: Has it been three years already?

Care Consultant Jones: Yes. I have to prepare my patient portfolio and revise for the exam. I shouldn’t have left it all to the last minute!

Dr Jones: Enjoy yourself! Goodbye Dr Jones. I hope you visit me again soon.

Care Consultant Jones: Grandfather, you know that the nursing unions put a stop to the term ‘doctor ‘a long time ago.

Dr Jones: Yes I do know. The term supposedly increased the divide between health care professionals. It was all politically correct non-sense. I just like calling you ‘doctor’. However, if you insist, Goodbye Care Consultant Jones.

- – -

Footnotes

1. All patient rooms have a cleansing pod outside which automatically sprays your hands with anti-microbial. This was in response to the great MRSA and C.difficile epidemics of 2010 and 2020.

2. The hospitals of the future are all run jointly by Biotech companies and the government.

3. Patients are able to book into any hospital they wish for care.

4. All doctors in 2050 were issued with a PDA. It would allow them to continuously monitor a patient’s history, investigations and management plan from anywhere in the hospital.

5. In 2039 a medical student successfully sued his medical school for not providing a good enough education. His argument was that if he was to be held accountable for his actions as a doctor then he should be trained to a high standard in core competency. As a result of his action all medical schools were required to provide every medical student with a supervising doctor who would follow their progress and assure they received training in core competencies. An obligation to teach was written into every doctor’s contract with their employer.

6. Insurance premiums rose to over half a doctor’s salary following a spate of litigation from patients complaining about their care.

7. In 2012 a major review of medical school education suggested students could complete the course in two years if the pre-med undergraduate included all necessary pre-clinical credits.

8. All doctors receive points for teaching medical students. They must earn 100 points a year to fulfil their contracts with their employers.

9. Medical student places were vastly increased by the year 2050. The entry requirements dropped to allow most people to be eligible to become medical students. This was a reaction to a problem of under-recruitment in the late 2030s. This was thought to be because of medicine becoming a very low paying profession due to reduced working hours and very high insurance premiums.

10. The health tax was introduced in 2020. It was a specific tax paid by all to enable a free health service. It was raised every year subsequently until the Biotech companies agreed to buy and run hospitals. It was never repealed.

11. To save money the government agreed to allow Biotech companies to run the hospitals as private ventures whilst still receiving government funding to provide free health care.

12. The government pension for healthcare professionals was abolished for all new employees in 2020.

13. Nurses were given the right to prescribe medication in 2030.

14. The Government Minister for Health was made head of a new committee designed to issue evidence based practice guidelines to all medicare health professionals. Thus no guideline was issued without express government approval.

15. There were several Nursing strikes in the 2010s. These had a large influence in making the nursing unions a major government lobby.

16. The Stem Cell Research Bill of 2015 allowed any research to be carried out on Stem Cells from any origin including fetal stem cells. This was met with large protests in the country but eventually allowed Biotech corp to grow new human organs in the laboratory from a patient’s own genetically modified cells.

17. Doctors are required to re-register with the Provincial Medical Board every 3 years. They must review in a portfolio all the patients they have treated since their last registration and must take an exam to demonstrate core competencies appropriate for their level.

Bibliography:

1. Nurse prescribing: Politics to Practice by Mark Jones. Published by Elsevier Health Sciences, 1999 ISBN 0702023140

2. Malpractice litigation as a factor in choosing a medical specialty. West J Med. 1990 March; 152(3): 309–312

3. Perceptions on the standardization of psychiatric work: development of a care pathway. Psychtr Ment Health Nurs. 2004, Dec(11):705-13

4. Private finance initiative: Partnership between private and NHS is not necessarily wrong. BMJ. 2000 January; 320(7229): 250.

5. Medicare advantage: The Case for Protecting Patient Choice. Heritage foundation. link

6. Medical Education is it time for change? President’s address, American Association of Medical Colleges. May 8, 2007. link

7. B.C. nurses give an overwhelming Strike mandate/ UNA Stat.2001, april Vol 8(8) link

8. The ethics of Stem Cell Research: link

9. ‘Super surgery plan condemned’ link

10. Nurse-led clinic: 10 essential steps to setting up a service. Nursingtimes.net link

11. ‘Alberta considers private hospitals’ -Canada.com. link

12. Ontario health tax: link

13. The private hospitals act: Manitoba: (link)

14. General Medical Council (United Kingdom) – re-validation of medical license. link