Why is our healthcare system always in crisis? | Dr. Bill Ghali | TEDxCalgary
Summary
TLDRThe 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
- π The speaker humorously opens by referencing the Backstreet Boys but chooses not to perform.
- πΊ A CBC miniseries named 'The Greatest Canadian' aimed to identify the greatest Canadian through public nominations, with Tommy Douglas being the winner.
- π₯ Tommy Douglas, recognized as the father of Canadian Medicare, symbolizes the importance of healthcare in Canada's national identity.
- π€ The speaker questions the narrative of healthcare 'crisis,' noting that this concept has persisted for decades, worldwide.
- π The speaker explores definitions of 'crisis,' suggesting a critical but perhaps exaggerated portrayal of healthcare struggles globally.
- π©Ί Good healthcare, according to the Institute of Medicine, should be effective, safe, timely, efficient, equitable, and patient-centered.
- π¨π¦ 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.
- π 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).
- π The speaker references studies showing preventable deaths due to safety issues and praises micro-systems of excellence within Canadian healthcare.
- π 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 speakerβs 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
π 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 Canadaβs national identity.
π€ 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 Canadaβs healthcare system is in crisis or merely experiencing difficulties.
π 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.
πΊπΈπ¨π¦ 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.
π 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.
βοΈ 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.
Mindmap
Keywords
π‘Greatest Canadian
π‘Tommy Douglas
π‘Health care crisis
π‘Medicare
π‘Health system trade-offs
π‘Quality of care
π‘Patient-centered care
π‘Equity in healthcare
π‘Timely care
π‘Innovation 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 humankindβs 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
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