Sunday, September 13, 2009

Postcard From Canada: Why I Missed Obama's Speech

-- by Sara

True confessions: I missed the health care speech. While the whole lefty blogosphere was watching and blogging and tweeting, I was sacked out in my attic bedroom high on a mountainside in Vancouver, sleeping off a narcotic haze and the exhausting aftermath of a long night spent in the emergency room at Lions Gate Hospital.

President Obama tried to remind Americans all over again why health care reform matters. I didn't need a speech: I'd just had an up-close-and-personal encounter with a rational, not-for-profit, single-payer health care system. And it reminded me all over again (as it does every time we see a doctor here) why health care reform is the most crucial battle of our generation.

The health event was new to me, but pretty garden-variety as ER visits go. I had my first gallbladder attack. Not life-threatening, just the worst pain I can remember being in since the last time I was in labor. It started up just before dinner Tuesday night. At 2 am Wednesday, still awake and in worsening pain, I found my keys and shoes, stumbled down to the car (leaving the rest of the family sleeping), and drove the 25 blocks down to the hospital.

Four things in particular stood out about the hours that followed -- things that show just how different medicine is when the patients trump profit as the main priority, things that Americans need to understand if they're going to see through the chaos of this moment to the kind of future that's possible.

First, the waiting time between walking in the door and being admitted was literally about 45 seconds. American conservatives have filled people's heads with images of Canadians packed into old, worn-out, badly-lit, overcrowded emergency rooms bustling and echoing with writhing, moaning souls enduring waits that can stretch to days. Sorry to blow the fantasy, but last night, I walked into a newly-remodeled, gently-lit, serenely quiet lobby that I had completely to myself. There wasn't another human being in sight. Even the receptionist had apparently taken a break.

I doubled over on the counter, breathing through the pain (those long-ago Bradley childbirth classes are still paying off). Moments later, a nurse appeared to check me in. With a quick swipe of my BC provincial care card, my complete medical files glimmered onto his computer screen. He put a thermometer in my mouth, then confirmed the basic data while a printer spit out my wristband. The whole check-in process took under three minutes.

"It's really quiet tonight," I noticed, trying to look nonchalant while clutching my stomach.

"Actually, we're pretty full." This was my first visit since a recent remodel created a huge new ER ward. (They're expecting the world here: this particular hospital is the closest one to the skiing venues for next February's Winter Olympics, and also one of the province's major orthopedic centers. It's where Canada's athletes come to get put back together.) There were lots of people here -- but they were all already comfortably checked in and settled away in beds, rather than milling around the lobby waiting to be tended. In another three minutes, I was settled in, too.

Second: You don't realize how much politics -- in this case, the war on drugs -- has warped medical care until you see how differently non-American doctors and nurses deal with pain management. Since Canada sees drug abuse as a social problem, not a law enforcement one, it's stubbornly resisted several ham-handed attempts by the American government to get it to crack down on doctors who persist in seeing codeine and morphine as useful medications. While Health Canada does keeps tabs on individual doctors' prescribing habits, docs are given vastly more discretion in managing their patients' pain than their US counterparts are. If you're hurting, the docs here will calmly and generously prescribe painkillers -- good ones, serious ones, the yummy kind that really do the job. (And yeah, I guess that would explain why the whole ER ward was so eerily quiet, too.)

So it was that, minutes after my arrival, the ward nurse tucked me in and hooked me up to an IV drip with saline and anti-nausea medications. "Would you like some morphine with that?" she asked, in the same casual and pleasant voice with which a waiter might offer you cream for your coffee. My inside voice, battered after a long evening of agony, jumped up and hollered: "YESSS! Oh, HELL yes!" My outside voice sweetly smiled back: "That would be lovely." In moments, eight hours long hours of accelerating pain finally subsided -- and I went to sleep, waking only occasionally from my opiate bliss to find myself being wheeled out for this test or that as night turned to morning.

Third: About those electronic medical records. I am a fan. A big one. Everybody in the BC health care system has their records in one big database, accessible within seconds in every doctor's office and hospital in the province. The doctors and nurses never have to waste a lot of time taking history, or guessing at the doses of the meds I'm taking (it turns out that dutifully reporting that "I think I'm taking half of that round green pill now" is surprisingly unhelpful) or wondering where those X-rays disappeared to, or cross-testing my blood type. It's all there -- including digital copies of all the X-rays, ultrasounds, mammograms, and EKGs I've ever had here. Every doctor that writes a prescription knows exactly what else I've been prescribed. It's hard to overstate how much this improves the level of care, even as it cuts costs.

(It's also another reason doctors can be so generous with painkillers. Since all the information from everywhere ends up in the same file, the e-records system automatically notices and flags doctor-shoppers and drug-seekers -- which, in turn, allows doctors to be much more confident about giving non-addicts what they need without being worried that they're enabling somebody they shouldn't be.)

Beyond the vast improvements in individual care, though, there are also huge public health benefits. Qualified public health researchers can get access to the population-level data in the files -- though they need special authorization (and a damned good reason) to access individual patients' names. They use this data to compare the pool of patients who've had treatment A against those who got treatment B; and issue impartial advisories as to which is better. They can instantly track emergent epidemics like SARS, or notice geographic anomalies affecting one area or another, or figure out who got a batch of bad vaccine. As genetics-based medicine emerges (and BC is one of the world centers for this), the growing pile of data in this system will eventually become a global asset in the effort to correlate the various genetic and environmental interactions that contribute to illness or health.

Do I worry about privacy? Not in Canada, much. This is a country that has a national Office of Privacy. The privacy laws are strict enough that the prairie provinces are doing a booming business in storing records for assorted American enterprises, where they're beyond the long snooping noses of Homeland Security and other public and private buttinskis. In theory, only authorized medical personnel get access to my records. Both provincial and national laws (and the general mood of the country) support the idea that we've got privacy rights that deserve careful respect.

At the same time, I'm not at all sure Americans are ready for this. Canada's system works because the country has a strong culture of privacy, and an even stronger bulwark of laws that back that up. Americans have almost no data privacy to speak of compared to most of the rest of the industrialized world, and no real expectation of having any. Frankly, I wouldn't trust any American e-records system until our whole cultural and legal framework around data privacy is overhauled. I trust the Canadian government to get it mostly right. I don't trust any American government not to sell my data to ChoicePoint or hand it over to the NSA. Until that changes, y'all be careful.

Finally, the last thing I noticed about last night was something that wasn't there. I'm talking about that little meter in the back of my head, the one that whirred and spun and ticked off every charge from the minute I walked into an American ER until the minute I walked out again. The IV. The X-rays. The box of Kleenex, the Tylenol, and the barf pan. The crappy food (if you're lucky enough to get any). Even with good insurance, the co-pays alone on eight hours in the ER could bust the family grocery budget for the next three months. That big number hanging over my head was always a real distraction from dealing with whatever crisis actually put one of us there. No matter what the presenting condition was when we arrived, I always seemed to have a bad case of heartburn when we left.

Contrast that with last night, when my glorious morphine dreams were completely untroubled by the sound of that mental meter. By the time they checked me out at 10:30 am, I'd had a whole bank of diagnostic tests, including a long and detailed ultrasound exam that found twin bouncing baby gallstones. The ER then handed me off to an internist for further exploration of the issue. (I see her next week -- it's already set up.)

No bills. No worrying about how to pay for the surgery, either -- that will be covered, too. The morning nurse (the fabulous and charming Trish) pulled the IV. I got dressed, picked up my purse, and left. And that was it. No pain. No worries. No heartburn.

And that's all it should ever be. And could be. And will be, if we keep leaning on Congress to get this thing done right.

(Cross-posted from

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