Why is our healthcare system always in crisis? | Dr. Bill Ghali | TEDxCalgary

Summary

The speaker explores the concept of a 'healthcare crisis,' using examples from Canadian and American systems to discuss the challenges faced by healthcare globally. They highlight six dimensions of quality healthcare: effectiveness, safety, timeliness, efficiency, equity, and patient-centeredness. Despite ongoing challenges such as wait times and inefficiencies, the speaker suggests that the term 'crisis' may be exaggerated, and instead argues for viewing healthcare issues as persistent challenges. They emphasize the potential for innovation and trade-offs, advocating for nuanced thinking around healthcare rather than succumbing to fear of perpetual crisis.

Takeaways

• 😀 The speaker humorously opens by referencing the Backstreet Boys but chooses not to perform.
• 📺 A CBC miniseries named 'The Greatest Canadian' aimed to identify the greatest Canadian through public nominations, with Tommy Douglas being the winner.
• 🏥 Tommy Douglas, recognized as the father of Canadian Medicare, symbolizes the importance of healthcare in Canada's national identity.
• 🤔 The speaker questions the narrative of healthcare 'crisis,' noting that this concept has persisted for decades, worldwide.
• 📉 The speaker explores definitions of 'crisis,' suggesting a critical but perhaps exaggerated portrayal of healthcare struggles globally.
• 🩺 Good healthcare, according to the Institute of Medicine, should be effective, safe, timely, efficient, equitable, and patient-centered.
• 🇨🇦 Comparing Canadian and American healthcare systems, Canada offers equitable care but faces challenges with timeliness, while the U.S. has timely but expensive and less equitable care.
• 🔄 The speaker introduces the idea of trade-offs in healthcare: improving one area (e.g., timeliness) may lead to compromises in another (e.g., efficiency).
• 📚 The speaker references studies showing preventable deaths due to safety issues and praises micro-systems of excellence within Canadian healthcare.
• 🌍 Ending on a hopeful note, the speaker emphasizes the ability of humankind to innovate and address healthcare challenges, moving from 'crisis' to 'perpetual challenge.'

Q & A

What was the premise of the CBC miniseries 'The Greatest Canadian'?

The CBC miniseries 'The Greatest Canadian' aimed to identify the greatest Canadian of all time through public nominations and celebrity advocates representing the top ten finalists.

Who were some of the notable finalists in 'The Greatest Canadian'?

Some of the notable finalists included Pierre Trudeau, Terry Fox, David Suzuki, Wayne Gretzky, and Don Cherry.

Why was Tommy Douglas chosen as the greatest Canadian?

Tommy Douglas was chosen because he was the premier of Saskatchewan and is considered the father of Canadian Medicare, which is a significant part of Canada's national identity.

What was the speaker’s main point in comparing healthcare systems in Canada and the U.S.?

The speaker highlighted that both systems have strengths and trade-offs. The Canadian system is more equitable and cost-efficient but suffers from longer wait times, while the U.S. system offers more timely and effective care but is expensive and less equitable.

What does the speaker mean by the term 'crisis' in the context of healthcare?

The speaker uses the term 'crisis' to describe a difficult and dangerous situation in healthcare that requires attention, such as safety issues, long waiting times, or inefficiencies in the system.

How does the speaker challenge the idea that healthcare is always in crisis?

The speaker argues that while healthcare often appears to be in 'crisis,' it may be more accurate to describe it as facing 'perpetual challenges.' These challenges can be addressed through innovation and making trade-offs between aspects like timeliness, efficiency, and equity.

What are the six dimensions of quality healthcare according to the Institute of Medicine?

The six dimensions are effectiveness, safety, timeliness, efficiency, equity, and patient-centered care.

What example does the speaker give regarding safety issues in healthcare?

The speaker mentions that in the U.S., a study found that the equivalent of a Boeing 747 crashes daily due to preventable medical errors, and a similar Canadian study found 20,000 preventable deaths annually.

How does the speaker use the concept of trade-offs in healthcare?

The speaker explains that improving one aspect of healthcare, such as timeliness, might compromise another, such as cost-efficiency or equity. These trade-offs are a reality in managing healthcare systems.

What optimistic perspective does the speaker offer about the future of healthcare?

The speaker suggests that despite challenges, there is room for optimism through human innovation, as seen in advancements in life expectancy, treatment of diseases, and the potential for improving healthcare systems over time.

Outlines

00:00

😀 Introduction and the Greatest Canadian Nominees

The speaker opens with a light-hearted comment about not performing a Backstreet Boys routine and then discusses a CBC miniseries from ten years ago aimed at finding the 'Greatest Canadian.' The process involved public nominations and celebrity advocates making a case for each finalist. Some finalists include Pierre Trudeau, Terry Fox, David Suzuki, Wayne Gretzky, and Don Cherry. Ultimately, Tommy Douglas, the father of Canadian Medicare, was chosen as the greatest Canadian, emphasizing the importance of healthcare in Canada’s national identity.

05:03

🤔 Defining the Health Care Crisis

The speaker transitions to discussing the widespread notion of a 'crisis' in health care. They explain that the term is often used globally, not just in Canada, and has been in circulation for decades, suggesting the persistence of the problem. A crisis, according to Merriam-Webster, is defined as a dangerous situation requiring serious attention, and the speaker uses this to question whether health care systems are in a true crisis or just facing ongoing challenges. The speaker intends to explore whether Canada’s healthcare system is in crisis or merely experiencing difficulties.

10:04

📊 Dimensions of Health Care Quality

The speaker introduces the Institute of Medicine's six dimensions of healthcare quality: effectiveness, safety, timeliness, efficiency, equity, and patient-centeredness. They emphasize that for care to be good, it must meet these criteria, explaining how failures in any of these areas, such as preventable deaths or long waiting times, can create the perception of crisis. The speaker compares the American and Canadian healthcare systems, noting how trade-offs between these dimensions shape the differences, such as the U.S. system's efficiency but lack of equity and the Canadian system's focus on equity but delays in care.

15:06

🇺🇸🇨🇦 Comparing U.S. and Canadian Health Care Through Dual-Experience Users

The speaker references a study called the 'Americans in Canada' study, which collected insights from people who had experienced both the U.S. and Canadian healthcare systems. These dual-system users appreciated the equity and cost-efficiency of the Canadian system but were troubled by delays in care. In contrast, they valued the timeliness and efficiency of the U.S. system, though at the cost of higher out-of-pocket expenses and less equity. This comparison shows that both systems have strengths and weaknesses, with the overall conclusion being that whether one system is better than the other depends on individual priorities.

📈 Challenges in Healthcare: Crisis or Perpetual Struggles?

The speaker argues that while the Canadian healthcare system has issues, like long waiting lists, preventable deaths, and rising costs, there have been significant improvements, such as better life expectancy, heart disease treatment, and cancer survival rates. They mention innovative approaches highlighted in books like *Prescription for Excellence* by Dr. Michael Rachlis and *The Rational Optimist* by Matt Ridley. These works argue that human progress, including in healthcare, comes from innovation and collaboration, leading to continual improvement. The speaker suggests we are not in crisis but facing challenges that can be overcome with innovation.

⚖️ The Importance of Trade-Offs in Health Care

In closing, the speaker reiterates that healthcare is about making trade-offs. A more equitable system might be less efficient, and efforts to make care timelier might increase costs. They urge the audience to adopt a nuanced view of healthcare, recognizing these trade-offs as part of the system's complexity. Citizens, voters, and patients should stay informed and engaged in improving healthcare rather than resigning to the idea of perpetual crisis. The speaker concludes by rejecting the notion of 'crisis' and emphasizing the importance of facing healthcare challenges with optimism and a commitment to innovation.

Keywords

💡Greatest Canadian

The 'Greatest Canadian' refers to a public nomination process organized by the CBC to identify the most influential Canadian in history. This concept frames a large part of the script's discussion, listing notable figures like Pierre Trudeau and Wayne Gretzky, while focusing on Tommy Douglas as the winner due to his role in establishing Canadian Medicare.

💡Tommy Douglas

Tommy Douglas, the premier of Saskatchewan from 1944 to 1961, is referred to as the 'father of Canadian Medicare.' His role in creating the national healthcare system exemplifies the importance of healthcare to Canadian identity, as highlighted by his selection as the greatest Canadian in the CBC miniseries. His contributions are a central theme in the script's reflection on health and policy.

💡Health care crisis

The concept of a 'health care crisis' is explored as a widespread concern across various countries and eras. The speaker questions whether healthcare is truly in a constant state of crisis or if it's better framed as an ongoing challenge. The script emphasizes that healthcare systems, including Canada's, are often labeled as being in 'crisis' due to issues like preventable deaths, waiting times, and system inefficiencies.

💡Medicare

Medicare in the context of the script refers to Canada's publicly funded healthcare system, which was pioneered by Tommy Douglas. The term is used to illustrate the idea that healthcare is a source of national pride in Canada and a defining feature of Canadian identity, with Medicare representing a major achievement in public policy.

💡Health system trade-offs

Trade-offs in healthcare refer to the balancing act between different dimensions of care, such as timeliness, efficiency, and equity. The script explains that improving one aspect of the healthcare system (e.g., reducing wait times) may lead to compromises in another area (e.g., increased costs). This notion of trade-offs is central to understanding how health systems operate and evolve.

💡Quality of care

Quality of care is discussed through six key dimensions identified by the Institute of Medicine: effectiveness, safety, timeliness, efficiency, equity, and patient-centeredness. The speaker uses these dimensions to evaluate both the American and Canadian healthcare systems, highlighting the strengths and weaknesses of each and stressing the importance of these qualities for a well-functioning system.

💡Patient-centered care

Patient-centered care is the principle that healthcare should prioritize the needs, emotions, and participation of patients in decision-making. This is one of the six dimensions of quality care mentioned in the script, emphasizing the importance of making healthcare more responsive to individual patients rather than treating them as passive recipients of services.

💡Equity in healthcare

Equity refers to ensuring that healthcare is fair and accessible to everyone, regardless of factors such as income, education, gender, or ethnicity. The script contrasts the American and Canadian systems, noting that while the American system may be less equitable due to disparities in coverage, the Canadian system aims to provide more equitable access to care.

💡Timely care

Timely care is one of the dimensions of quality healthcare, emphasizing that patients should receive treatment without unnecessary delays. The script contrasts the Canadian and American systems, noting that while the American system generally provides more timely care, the Canadian system often struggles with long wait times, which can lead to distress and worse health outcomes.

💡Innovation in healthcare

Innovation in healthcare refers to the ongoing development of new treatments, technologies, and systems to improve care. The script highlights how technological and procedural innovations can address the challenges facing healthcare systems globally, and it suggests that continuous innovation is essential for overcoming perceived 'crises' in healthcare.

Highlights

The speaker humorously mentions a suggestion to start with a Backstreet Boys routine but decides against it.

The CBC miniseries 'The Greatest Canadian' aimed to identify the greatest Canadian of all time through public nominations.

Famous Canadians like Pierre Trudeau, Terry Fox, David Suzuki, Wayne Gretzky, and Don Cherry were among the top ten finalists.

Tommy Douglas, the father of Canadian Medicare, was selected as the greatest Canadian, emphasizing the importance of healthcare in national identity.

The speaker connects Tommy Douglas's legacy with how health care is a crucial issue globally, as seen with Obama's Affordable Care Act (Obamacare).

There is a persistent narrative of a healthcare 'crisis' worldwide, but the speaker questions whether we are truly in crisis.

The definition of 'crisis' is explored, referencing the Merriam-Webster dictionary, linking it to health care anxieties.

The Institute of Medicine defines good healthcare as being effective, safe, timely, efficient, equitable, and patient-centered.

The U.S. healthcare system is timely and effective but inefficient and inequitable, while Canada's system is equitable and cost-efficient but less timely.

Dual system users (those familiar with both Canadian and American healthcare) highlight the trade-offs between equity and timeliness.

The speaker questions if we are in 'crisis' or simply facing ongoing 'challenges' like safety concerns, long waiting lists, and rising costs.

Despite flaws, life expectancy and survival rates for diseases like cancer are better than ever, reflecting progress in healthcare.

Innovation, particularly in micro-systems of healthcare excellence, is vital to improving the system.

The notion of 'rational optimism' is introduced, highlighting humankind’s history of innovation and cooperation leading to progress.

The speaker concludes that the challenges in healthcare are not insurmountable but require careful consideration of trade-offs between dimensions like timeliness and equity.

Transcripts

well thanks and and hello everyone it's

a real honor to be here some colleagues

from the university told me that a cool

way to start would be to break into a

Backstreet Boys routine with my head

bite but I don't think I'll do that all

right

so about ten years ago the CBC had a

miniseries called the greatest Canadian

and the objective of the exercise was to

identify who the greatest Canadian of

all time is and there was a process of

public nominations where the public

could nominate anyone could nominate

themselves that they wanted to and then

ten finalists were selected and the ten

finalists were then represented by

celebrity advocates and the celebrity

advocates made the case for so-and-so

being the greatest Canadian and I'll

just list some of the ten finalists and

I'll I'll gauge from the nods in the

audience whether you feel that you

should have been finalists Pierre

Trudeau one of our greatest prime

ministers so some people are nodding I

see Terry Fox unfortunately a cancer

victim but clearly a person who who

conquered cancer in many ways through

what he did and the legacy of

fundraising that he created David Suzuki

an educator scientist environmentalist

clearly a great Canadian that many

people have learned tremendously from

Wayne Gretzky whether you're an Edmonton

Oilers fan or not clearly one of the

greatest I think the greatest Canadian

hockey player to ever play hockey player

to ever play and clearly part of the

national identity hockey Canada they go

hand in hand

Don sherry was chosen that was a more

controversial choice and I hear that in

your reaction

the winner was Tommy Douglas Tommy

Douglas I like that's actually kind of

surprising why Tommy Douglas

well Tommy Douglas was the premier of

Saskatchewan between 1944 and 1961

and he's also considered to be the

father of Canadian Medicare his

selection as the greatest Canadian

overall those names I listed shows you

how health care is part of our national

identity and how despite imperfections

our health care system is a source of

national pride now if we look south of

the border if I were to ask you is there

any single policy of the Obama

administration that is the subject of

conversations around the across the US

regardless of people's political stripes

left or right I think most of you would

agree that Obama care would be right up

there among the issues that people want

to talk about and that speaks to the

fact that we as citizens wherever we

live care about our health and we care

about our health care and so that's

that's a reality that I want to bring

across as a first as a first key point

the next point to make is that when we

think about health and health care were

anxious because we worry about our

health and when we read about our health

care system being in trouble that makes

us anxious and we actually often hear

about quote unquote crisis the health

care system is in crisis we hear this

and you could even in the last week

there have been headlines in our

newspapers local and national saying

there our health system crisis issues

and I want to take a little bit of time

thinking about that crisis word we hear

this here in Canada if you look south of

the border there's news coverage about

the American system in crisis if you

look overseas in Europe all healthcare

systems have been described as being in

crisis in Asia that in China and South

Korea in Thailand in Mexico you can

google health care crisis and a country

and you're going to get hits so there is

crisis in health care everywhere that's

what we're told and if you think now

we're in 2014 if you look back to 2004

you Google health care crisis there are

stories about the health care system in

crisis in the 2000s in the 1990s in the

1980s

and if you go back to the Tommy Douglas

years the whole thing about creating

Medicare was because healthcare was in

crisis so we have crisis everywhere and

always this what we're told I want to

take some time and break this down so I

went to merriam-webster to look at the

word crisis so crisis is a difficult or

dangerous situation that needs serious

attention that definition speaks to

crisis and an alternative definition an

unstable or crucial time or state of

affairs in which a decisive change is

impending especially one with the

distinct possibility of a highly

undesirable outcome a good definition

and I think that speaks to what crisis

is and what I want to do here is speak

to you as citizens who care about health

and healthcare as voters who vote in and

vote out governments that have to answer

to this crisis in health care and also

as patients who have to experience care

with the nervousness that the system

that you're in is in crisis and I'm

going to pose the question are we really

in crisis and I want to take us through

a bit of a more nuanced to discussion

about our health care systems to ask the

question do we have good health care and

I'm going to do that from a Canadian

perspective but speaking in generic

terms that are relevant to systems

anywhere

the Institute of Medicine which is an

American think tank focusing on on

issues of health and health care has

developed a definition of quality that

has six dimensions and it's really a way

of thinking of what the ingredients are

for good health care so for health care

to be good

it must be effective as the first point

an effective care involves the use of

treatments and diagnostic tests that are

known to be beneficial and the the

prevalent use of those those things that

are known to be beneficial so care must

be effective first and foremost care

must also be safe so when we do things

to patients we can't harm them and we

have to make sure that our healthcare

facilities and

information systems protect patients

from harm brought that can be brought to

them the court from the system

the Institute of Medicine in fact did a

study back in the 1990s estimating that

every day in the United States there's

the equivalent of a Boeing 747 crashing

due to accidents or errors in healthcare

it's crazy and here in Canada we did a

similar study suggesting that there are

20,000 preventable deaths in Canadian

healthcare due to suboptimal safety that

does actually sound a little bit like a

crisis back to the dimensions for health

care to be good

it must be timely waiting for health

care is distressing and at a minimum

weights cause emotional distress but

even in conditions like heart disease or

cancer delays in in care or non timely

care can actually lead to death or bad

outcomes for patients so care needs to

be timely care needs to be efficient and

resource resource protective so we can't

have waste in our system unnecessary

testing needs to be curtailed expensive

medications need to be replaced with

equivalent alternatives that are priced

better a cost-efficient system is an

element of quality care needs to be

equitable so a patient's ethnicity their

gender where they live their income

their education none of those factors in

an ideal world anyways should influence

the care that they get so care needs to

be equitable and last but not least care

needs to be patient-centered and

patient-centered care is really the core

where is real I mentioned it last but

it's it's kind of first and foremost

cares about the patient so care needs to

be attentive to their emotional needs

their information needs and patients

need to be involved in decisions about

their care so those are the dimensions

of quality up on a slide for you to

think about so just to drive this home

I'll just now compare the American and

Canadian health care system a little bit

to just bring out these dimensions and

to bring in the notion of trade-offs in

the American healthcare system there are

considerable facilities and capacity so

carries timely weights are not often

talked about in American healthcare and

care is effective new beneficial

treatments are quite swiftly adopted

into care that's perhaps at the expense

of efficiency and merit the American

healthcare system is the most expensive

healthcare system in the world with 17%

of gross domestic product going to the

to delivery of healthcare and it's also

not a very equitable system with

millions of uninsured or underinsured

Americans the Canadian system meanwhile

is more equitable and yes it is more

cost efficient we have a universal

coverage that makes care somewhat more

equitable but it's much less timely when

those are the sorts of trade-offs that

you have and when you intervene to

improve one dimension you had you may

compromise another dimension so this is

this notion of trade-offs a few years

back a friend and colleague of mine

Stephen Lewis led a study with

colleagues here at the University of

Calgary called the Americans in Canada

study and the objective of the study was

to get the perspectives of dual system

users who had so to speak test driven

the two systems recognizing that the

dual experience is a rich a rich

opportunity to learn from people who've

had experiences in two systems and and

many of you will remember the movie

sickled from a number of years ago a

Michael Moore movie that painted a very

very rosy picture of the Canadian

healthcare system that's probably too

rosy even though people want to feel

that our system is great here in Canada

and we wanted a tidy answer or the

Canadian system is awesome or the

Canadian systems not so great but we

actually got a very nuanced answer the

Americans who live in Canada told us

that they embraced the notions of equity

they embraced the cost efficiency and

the lack of out-of-pocket payments for

their health care but at the same time

they they were really troubled by the

lack

timely access to diagnostic testing

specialists and so on and those were the

the inverse of what they liked in the

American system so we wanted a crisp

answer and the answer we got from the

Americans in Canada was which system is

better it depends so back to the

question of crisis

do we have crisis well on the one hand I

could say and I'm gonna focus on Canada

now 20,000 preventable deaths due to

lack of safety waiting lists distressed

patients who aren't getting

patient-centered care rising health care

costs anxiety anxiety comparisons

according to the Commonwealth Fund with

European countries that aren't so

flattering for Canada we we like to look

south at the border and say Oh our

systems selectable and good but

comparisons to European health care

systems aren't so favorable for Canada

those all speak to yes we do have

potential crisis here but then I can

flip it around and say another way of

looking at it is to say that actually

life expectancy is greater now than it's

ever been

heart disease rates are lower care of

hypertension heart disease stroke is

better than it's ever been cancer

survival rates are better than ever

there's been tremendous progress there

is a lot of innovation in our system and

for that I want to point you to a book

called the the prescription for

excellence written by dr. Michael

reckless who is a health policy analyst

at the University of Toronto and he has

written about micro systems of

excellence in the Canadian healthcare

system were patients the good patient

care is president efficient protocols

for streamlining patients through

clinics are in place and he speaks of

needing to multiply this excellence

throughout the system we hear from the

Canadian Institute for health

information that there's also a leveling

off of spending now it's with a slight

reduction in the worrisome trends of

spending on health

and innovation is at the core of this

enhancement continuing along that same

line I want to draw your attention to a

book by Matt Ridley called the rational

optimist and this came out about two

years ago it's not called the pathologic

optimist it's the rational optimist and

I actually embraced these notions and

some people tell me I'm way too

optimistic about things like my favorite

hockey team winning the Stanley Cup

every year and I don't disclose that

here in front of a mixed crowd but the

notion of the rational optimist is that

life expectancy is greater than ever and

economic prosperity on a global scale is

better than it's ever been countries

have had large proportions of their

their people move above the poverty line

and the foundation of this progression

of humankind over centuries has been

specialization collaboration cooperation

and technologically based innovation

innovation leads to advancement of

humankind through the centuries so back

to health care and back to my

fundamental question are we in perpetual

crisis or are we perhaps more in

perpetual challenge and the challenges

are relating to this slide again care

that needs to be safe or care that isn't

timely enough care that isn't efficient

enough care that isn't equitable enough

care that isn't sufficiently

patient-centered I think those are the

challenges and I don't think we should

throw our hands up in the air and say Oh

crisis it's impossible I don't think

that's constructive we have challenge

but we also have the ability of

humankind to innovate and innovate and

innovate we've done it for centuries we

can continue to do it it's all about

trade-offs a system that's more timely

may become less efficient and might cost

more a system that's more equitable

might become less timely because

equitable care might make it difficult

to get the wealthy to get their surgery

in one day those are the trade-offs that

we need to make us as humankind as

societies and just really in closing

I'll say I've brought these ideas

forward to try to give you nuanced

thinking around health care to make you

think as again the citizens who care

about these issues the voters who vote

in and out the governments that have to

decide on these issues and ultimately

the patients who receive care in the

system I wanted to share these thoughts

with you do we have crisis in healthcare

I say crisis crisis thank you