Is the best interest of the patient the only interest to be considered?

"The best interest of the patient is the only interest to be considered."

"The needs of the patient come first."

Dr. William Mayo

One of the things that I admire most about the Mayo Clinic is it's commitment to the interests and needs of the patient. The spirit of the aphorisms of Dr. Will is one of the founding principles of the Clinic and it is reflected in their mission statement. And it is not just "talk". I see concrete examples of it every day from the people working here; and in the way the institution functions; and in the way the institution is organized. This attitude of the patient-first seems to permeate the walls of this place. It is inculcated from your arrival here at the Clinic, while making direct reference to the Mayo brothers and drawing upon it's rich, yet short, history. For me this is one of the pleasures of doing a fellowship here.

However, my question is: Can this be truly applied to the health care system in Canada?

As Canadians, we have the misfortune of geographical juxtaposition to the United States. This has become our point of reference for patient care. Immediacy of access and treatment is common in the US for those that have insurance or those who can afford it. I think that these expectations are unrealistic for us in Canada. We should remember that up to a third of population in the US does not have access to the quality of medical care we do. Dr. Will's statements may need to be have the caveat "if you can pay".

The Canadian health care system is publicly administered. It is universal, so all Canadians benefit from it and should have access to it anywhere in Canada. The system aspires to be comprehensive in it's services. All these goals are laudable and I believe, like many Canadians, that our system should be supported and maintained without the corrosion of privitization. However, this comes with a price. Resources are limited and priorities may need to be set to ensure the sustainability of our system.

The ideals of the Mayo brothers may not be entirely compatible with the Canadian public health care system. Although we believe that the patient's needs and interests are of paramount importance, we also must consider the needs and interests of society in order to keep our system alive. For surgeons this is not self-evident. We are taught that the interests of our patient come first, which is a direct link to the Hippocratic tradition. There is very little formal education or training which addresses the realities of limited resources in our daily practice. Limited resources may place in direct conflict the interests of society with those of the patient.

Take, for example, the limited number of beds available in surgical intensive care units and the limited amount of operating room time to perform cardiac procedures. As a result, in order to provide cardiac surgical services to all it's citizens, patients may need to be on waiting lists. I believe this is an acceptable compromise. As surgeons, we should not become frustrated with this situation. In fact, we should understand that we are able to provide care to all our patients, even if they have to wait for some time to receive it. Patients also need to be made aware of this reality. In addition, they must be reassured by knowing that urgent or emergent care will provided without waiting.

New technologies, and even established ones, may not be immediately available to surgeons and their patients. In many cases, their is no access at all. One must consider that many of these new technologies are costly and sometimes of questionable value to the patient. That is to say, there is lack of evidence to support their widespread use. Without being nihilistic, it is important to recognize that newer does not mean better, and a public health care system must consider the cost vs. overall benefit to the population when making these technologies available. Surgeons need to participate in the decisions of application and implementation, rather that just criticizing the government for their inablitity or unwillingness to provide access.

A good example of the problem of new technologies are the methods now being used to the surgical treatment of atrial fibrillation. At least one department in Canada would like to purchase a machine and start performing this kind of surgery. I would like to point out that the evidence for the benefit of this technology is not very good, when it is compared to the standard cut-and-sew technique. Also, much of the hype about atrial fibrillation surgery with these machines is industry driven. Finally, I would humbly suggest that rather that investing in a new machine, send a surgeon to learn the cut-and-sew technique, which is probably better anyway. It is certainly cheaper.

It may be argued that by accepting waiting lists and the lack of access to newer technologies (and a myriad of other things), we are just bowing our heads and becoming complacent and complicit to the problems in our health care system. I disagree. By doing so, we accept that public health care has a price and balance must be found between the needs of the patient and those of society. To contribute within these confines, we all must find ways to become more efficient and less wasteful and we must pause before trying to introduce innovation. We also need to educate the public on the challenges we face and reassure them that they are being cared for well.

The purpose of this discussion is not to propose a solution to this problem. I only want to bring to the forefront the fact that it exists and acknowledge the difficulties it creates when treating patients. By ignoring it we bring about frustration in our own professional lives. Furthermore, by not educating the public about this, patient's expectations are becoming unrealistic. I certainly do not have educated or comprehensive knowledge about the structure and function of the Canadian health care system. My point of view arises from my own frustrations and my own experience in dealing with the system that I so much value and want to preserve.