Regulating Healthcare

By Gerrit Van Wyk.

Anything you can do I can do better.

In the 1946 Broadway musical Annie Get Your Gun, there is a song going: anything you can do I can do better than you can do. That seems to be the tune healthcare regulating authorities in North America sing to.

In North America, physicians regulate themselves, as opposed to many other countries where they are government regulated. That has two consequences; in Canada there are 13 separate and different regulating Colleges, each with their own rules and bureaucracies, and, secondly, it restricts physician movement across provinces. With a single regulator, that problem disappears.

Their mantra, or some may say ideology, is protecting patients, which is a complex undertaking, which in practice is simplified as protecting them from unscrupulous incompetent doctors, doctors from other provinces, and foreign trained doctors. The Colleges are governed according to laws made by provincial legislatures, which differ from province to province, and in addition make their own bylaws. It gives Colleges the right to license and investigate complaints, and mete out punish. Boards consisting of elected doctors and government appointed public members oversee the Colleges, which often have in-house lawyers on site. What you can see here is highly legalistic, typical command and control machine bureaucracies, of which the purpose is to preserve and justify the bureaucracy.

Doctors are not the only health workers regulating themselves, registered nurses, pharmacists, licensed practical nurses, etc., have their own authorities, which results in a cacophony of voices, and forests of Byzantine rules and regulations to surmount for the privilege to work. In countries with a single authority, all health professionals are licensed and overseen by one and the same authority.

Although a local College has all relevant documents on file, if for whatever reason a health worker decides to move to another province, it must get original copies of all the same documents again, and apply for a new license all over again. A simple solution like getting copies from a sister College which already vetted it is not good enough, which means the Colleges of different provinces don’t trust each other. The applicant is guilty/incompetent until proven innocent, and the out-of-province registering College incompetent until proven otherwise. Crawling over that hurdle is relatively simple if you are Canadian trained, but if you are one of the many doctors Canada poach from other countries, it becomes a brick wall, and you need a crowbar to get through it. Immigrant doctors are approached with deep suspicion and you have no recourse against that.

The core of licensing is your training, and the medical school awarding your certificate. There is a belief, not based on evidence or fact, that training and certification in Canada is superior to anywhere else. The belief is justified by the argument it is impossible to investigate and compare overseas medical schools to determine if they adhere to the same standards, therefore we must assume they, and their trainees, are inferior until proven otherwise. You now have a double bind; to get more doctors because of a physician shortage, Canada holds its nose and allow these poor souls to practice, provided they stay in trenches Canadian doctors won’t fight in.

Another barrier is language. There are many competent and brilliant physicians and other healthcare practitioners trained in excellent medical schools in Europe and elsewhere, but if they are deemed not to speak proper English, they can’t practice here. Their qualifications and experience become irrelevant.

The second justification is, to prove your competence you must pass the Canadian medical exams, and because many immigrant doctors fail these exams, they must be of inferior quality. Things are not that simple. Canadian medical students are coached and prepared for the exams; outsiders are not. But if you look at the data, Canadian doctors challenging exams in other jurisdictions do no better there than outsiders here, which means the exams are a matter of a different style, not substance. Secondly, we are prepared for the exams during training, but evidence shows if you challenge the same examination again 10 years later, the failure rate approaches that of the outsiders, many of whom have been in practice for several years. If local professionals were required to redo examinations 10 years after qualifying, it would not be a surprise if the outcome was carnage. When you are in medical school, you are likely to be single and living in res, outside doctors face the challenge of having to adapt to a new country and its rules and customs, work to support a family, and study for exams at the same time. That’s hardly a level playing field

The bottom line is this, what little research there is shows Canadian trained doctors on average perform no better than foreign trained doctors in practice.

It’s difficult to make a case that the right certificate leads to a license which protects patients from harm. In fact, rather than being proactive, Colleges wait for harm to occur before acting, which is like bayoneting the wounded after the battle. Instead of finding innovative ways to monitor doctors, and they do exist, Colleges find justifications for not doing so. In other words, Colleges do nothing to protect patients from harm before they are harmed, which makes a mockery of the mantra of patient protection.

A surprisingly small number of physicians are disciplined, not because the Colleges are not doing their jobs, but because most physicians practice ethically, and on average, competently. A recent report in one of the provinces found most crimes in general are committed by repeat offenders. If you look at College websites, there seems to be a similar pattern. The same names seem to keep cropping up. And like crime in general, most offenses are of a financial or sexual nature, or due to stupidity. Most people in society are not criminals and most doctors are not incompetent and a danger. In neither society or the medical profession is there a cure for stupidity though.

It seems to me having many Colleges doing the same thing is neither efficient nor fiscally sound, and unless patients in different provinces are of different flesh and blood, totally unnecessary for protecting the Canadian population. None are doing anything better than everyone else, and there is no reason why the job can’t be done more efficiently at a fraction of the cost by a single institution. I doubt the country has the political will to amalgamate them, and expect the existing bureaucracies to fight tooth and nail to justify their existences. I’d love to hear their reasoning.