The doctor dilemma: public policy and the changing role of physicians under Ontario medicare; S.E.D. Shortt; McGill-Queen's University Press, Montreal & Kingston; 1999 145 pp. $55 (cloth) ISBN 0-7735-1796-6 $19.95 (paper) ISBN 0-7735-1794-4
Medical professionals wait nervously on the shore, "divided among themselves and perceiving attack from without," writes family physician Sam Shortt in The Doctor Dilemma. Imagine a Viking dragon-ship full of berserkers from government, academia and the public, leaping onto the strand, brandishing their war axes. What will be the outcome of this raid? Will physicians survive, huddled next to the driftwood fire of medicare, or will they be forced to embrace a foreign culture imposed by the marauders? Shortt's answer is that a sea-change is inevitable and that assimilation within a new culture will be the best outcome for physicians.
Shortt sets the scene by recounting the amusing and preposterous attempt by a disgruntled physician to force the premier and the minister of health of Ontario to undergo psychiatric assessment for their inappropriate behaviour. He then considers five key policy areas: payment of physicians, supply and distribution of physicians, quality assessment in ambulatory care, the relationship between physicians and hospitals and the role of technology. Although most of these issues are familiar, this book is better than most accounts in both its perspective and its thoroughness. With this experience as a family physician, historian and policy analyst (he is now director of the Health Policy Research Unit in the Faculty of Medicine at Queen's), Shortt is well placed to put these issues in context. The book is rich with plundered treasure, containing over 400 references. It presents a clear-eyed synthesis of an important issue facing the profession, namely integrated care. Shortt is careful, however, to point out that this term is often confused with similar ones such as managed care, devolution, regionalization and comprehensive health organizations, and he admits to using these interchangeably.
The book is well written, and Shortt is not afraid of a vivid phrase for emphasis. There is an inevitability to each chapter as he outlines the issues, judiciously considers the evidence and reaches balanced conclusions. Published evidence, where available, is put to good use, and the constraints imposed by its lack are acknowledged. Two recurring themes are (1) that the anomaly of public payment for private practice has been directly responsible for the adversarial nature of physician-government relations, and (2) that the days of private practice are numbered and will eventually be replaced by public payment through some type of integrated system. Figure 1
The Doctor Dilemma will interest physicians who are puzzled about how events seem to be overtaking them and want to know where the profession is heading. Policy-makers anywhere in Canada who are mulling over the introduction of integrated health systems should read this book carefully. Shortt strongly advocates a crucial role for physicians in charting the future course of the health care system. No doubt there are one or two bruised bureaucrats who will beg to differ.
Many physicians will not like Shortt's central message that the introduction of integrated care will mean a shift from fee-for-service to some other form of reimbursement. This is likely to be a mix of sessional payments through an alternative funding plan for specialists at academic health sciences centres and a modified form of capitation for family physicians. Some may interpret the proposed policies as an attempt to control doctors, but Shortt maintains that they are about accountability, not control. A clear message is that until physicians learn to distinguish between the two they are unlikely to reside comfortably in the Canadian health care system.
How will the dilemma be resolved? Shortt argues that some form of integrated care is inevitable and will likely be for the better. He feels that the policy levers are already in place in Ontario and that it is time for some strong political hands to start pushing them. As it happened, Norse culture spread peacefully and gradually through Europe and the North Atlantic countries over several centuries. I rather think that this is how a new system, whether it be called integrated care or something else, will be diffused. Already, the Health Services Restructuring Commission of Ontario is soliciting pilot sites for integrated health care systems. Physicians would better serve the profession and their interests by becoming part of this process rather than having integrated care imposed on them. The Doctor Dilemma has the best interests of the profession at heart. It is worth reading for that fact alone.
Duncan Hunter, PhD
Director, Health Information Partnership; Eastern Ontario Region; Kingston, Ont.