My father, the patient

By Michael Gordon
Vice-President, Medical Services

The phone call came to the hotel in Mt. St. Anne, where I was spending a ski vacation with my family. My sister, Diana, who lives in Chicago, was telling me about my 89-year old father who recently moved into a retirement home there.
"Daddy fell this morning in the bathroom, but he seems OK," she explained. "I'm taking him for his hearing aid assessment."

A few hours later came another call: "He fainted while in the waiting room of the audiology clinic," my sister said, "and now he's in the hospital's emergency room."

The nurse picked up the phone as my father was being hooked up to the cardiac monitor: "He is in complete heart block," she informed me. Soon after, a cardiologist confirmed that my father needed to have a pacemaker installed, a procedure that I assured my sister and my father is safe and effective.

Following further phone calls over the next couple of days, it was decided that cardiac bypass surgery was required for my father's severe coronary disease. Surgery was booked for the day we were due to drive back to Toronto.

Messages we received en route told us my father had come through the surgery successfully. Over the next while, he progressed to the step-down unit, the ward, and then to a rehabiliation unit to prepare him for his return to the retirement home.

Curiously, two weeks before this happened, a work colleague of mine shared a comparable experience concerning his own elderly father. My colleague's father underwent cardiac by-pass surgery that had apparently been done with excellent results and exemplary care at a major Toronto teaching hospital.

My father's successful surgery and subsequent recovery were in sharp contrast to the experience of my late mother who eventually died following a severe stroke in a New York City hospital in 1995. Medically, I count that event as the worst I had witnessed in my career, including my training years in Scotland and residency in Israel. My mother had been taken to the closest hospital by ambulance and we were told that she was "too sick to move".

The attitudes of the nurses and administrative staff to whom I expressed my concerns were indifferent and dismissive and general nursing care was deplorable. When I mentioned this to some American friends, their comment was, "What do you expect from a city hospital?"

In the United States, a city hospital is a public institution that serves the poor and indigent. The concept that the wealthiest nation in the world still had a class system in hospital care was alien, if not a surprise to me. I had been practising medicine in Canada for more than 20 years but I did recall the "public" and "private" wards that existed in Boston when I was an intern in that city in 1967.

There has been a lot written lately about the "declining" state of Canadian medicare. Many people blame our single payer system for the decreased numbers of nurses and physicians and the increased waiting lists for some medical visits or procedures.

Some claim the problem is in the publicly funded system and propose that privatization is the solution.

What does all this mean for the older person in Canada? Would an increase in privatization make it better or worse for Canadians in general and older Canadians in particular? Or would it make it better for a few Canadians at the expense of the rest?

Many of the examples from the U.S. have focused on the issues of managed care and the many non-insured Americans who have marginal access to the health care system. Comparisons with countries like Britain, New Zealand and Australia,which have systems closer to Canada's -- but with elements of privatization -- focus on the pros and cons of a private health care tier.

I have a strong bias towards Canada's primarily publicly funded and universal system. I believe that despite an increasing component of privately funded care, most of these are still at the margins of health care and do not undermine its core elements.

The greatest benefit I find about our health care system is that, should someone require medical care, I as a physician don't have to determine whether that person is insured. The patient presents his or her health card and all hospital and physician-based services are covered. Unlike the U.S. system, coverage here includes everyone and does not depend on employment status and a generous employee benefits package.

In this country, which spends about 9.5 per cent of GNP on health care, as opposed to 15 per cent in the U.S., all Canadians are covered under the Canada Health Act. Under the American system, some 45 million citizens are insured but there are many more who aren't. Here in Canada, there are no financial barriers to hospital admission and no charges for hospital treatment for the elderly patients I deal with. Under the US system, medicare insurance premium payments and co-payments are levied for many elements of care, including non- hospital drugs. Although long-term care payment structures vary across Canada, the financial barriers and burden of long-term care are, by and large, substantially less than below the border.

In Ontario, the drug benefit program, which is one of the most generous in Canada, provides -- with few exceptions-necessary medications to seniors and individuals on social assistance. Even with the recently introduced co-payments in Ontario, it is very unusual for a senior not to receive a necessary drug, because a physician can request approval for drugs excluded from usual coverage.

In other provinces, the cost to higher income seniors may present a problem. The National Advisory Council on Aging (of which I am a member) has recommended to the federal health minister that a universal pharmacare program should be high on the agenda for future health care planning.

Although Medicare covers the cost of hospital and physician services, home care services are outside the mandate of the Canada Health Act. All provinces support some degree of home care, but with an increasing demand for early hospital discharge, cost-sharing initiatives and the recent cutbacks in home care in Ontario, many older people and their families find the costs of home care increasingly difficult to meet.

The many challenges to Canada's health care system, such as the shortage of health care professionals, also exist in other jurisdictions, including the United States.

I believe that the Canadian public, especially the elderly, is well served by our publicly funded system. At the same time, though, I think improvements must be made to offset the enormous outlay of time and money families make in an effort to care for their aging relatives.

Beginning next month I'll be contributing a monthly column of practical advice on aging issues to the Star's Life/Health section.

Effects of Aging: Dr. Michael Gordon, seen here with patient Sarah Martin, worries about the effect that proposed health care "reforms" will have on his elderly patients.

It will be of interest to those of you, like me, who are getting on in years and perhaps coping with the responsibility of caring for an aging relative.

Even with my 25 years of experience in geriatric medicine, it's been a shock to see the many changes that have taken place in my father's functioning and needs over the past few years. Like the children of my patients, I find that the usual parent-child relationship is reversed. My sister and I now have the responsibility - and the opportunity - to make sure that our father's needs are met, as he grows older and less able to look after himself.

Among the issues I hope to address: recognizing when outside help is needed, making the home safer for an aged relative; coping with dementia; improving nutrition; dealing with physical and emotional setbacks, and deciding when long-term care may be required.

I hope to help readers respond to these challenges, consider the next steps, and understand the resources available to seniors and their families.

Special To The Star (07-13-2001)
Reprinted with permission from Toronto Star