So what’s up, docs?

A scene from Håvard Bustnes’ Health Factory.

The 1980s may be remembered for Madonna, Tom Petty and Phil Collins—or are those the the Superbowl halftime shows of the past decade?—but it was also a turning point for the perception of government in both the United States and Britain. As the great (sarcasm) Ronald Reagan said, “government is not the solution to our problem; government is the problem.”
This ushered in a new paradigm of absolute and obsequious commitment to the market. America was built on competition, it was said, and its improvement was dependent on unfettered capitalism.
The market is a brilliant tool and an important facet of good democracies. But the overzealous commitment to wholesale privatization is deeply flawed. Competition amongst retailers and car makers forces innovation because these industries are based on consumer desires, and providing excellent products is a powerful incentive. These tenets are absent in other fields, the most obvious of which is health care, an industry based on need and trust.
The idea that government-run health care is a bloated bureaucratic mess comes from this era (which also brought us shoulder pads, big hair and Sixteen Candles), and it was the decade in which Britain and Norway partially privatized their health care systems, exemplified by Margaret Thatcher’s famous “hospital of my own choosing” speech.
Håvard Bustnes’ Health Factory documents the effects of this pseudo-privatization,where government funds create a faux market. In Norway, the state pays hospitals by the procedure; birthing a baby, for example, nets a Norwegian hospital 18,000 kroner. But should a slow-paced birth require a vacuum, the hospital pockets an additional 10,000 kroner. Needless to say, the threshold between “normal” and “requiring expedition” starts to wane fairly fast.
According to nurses in Norway, hospitals go as far as to chastise employees for an abundance of “normal births” in a given month.
A prominent Norwegian doctor sums up this state of affairs deftly: paying by the procedure incentivizes quantifiable items, shifting focus away from improving health. A hospital would rather treat 10 easy patients as opposed to five difficult ones, since the former has a better ratio of time to value. It also discourages the human side of health care. What value is there in holding someone’s hand who is in deep crisis, he asks, and how long do you hold on before it becomes unprofitable?
The obvious ethical issue of ranking patients by profitability aside, a hospital market isn’t feasible because healthy markets require informed consumers. Consumers chose VHS over Betamax because they could easily deduce the former’s cost-benefit superiority. This choice eventually drove Betamax out of existence (to the dismay of many picture-quality purists). But making this kind of decision about your health care provider requires knowledge of a much more esoteric nature. And, as is argued in the film, consumers don’t necessarily want choice when it comes to which hospital to go to; they just want good care. Competition, it seems, is not the golden goose the Iron Lady made it out to be.
Obviously, public health care has its own major flaws; Canadians know this well. The Big Wait addresses one of these: the inability of international medical graduates to practice medicine in Canada. IMGs, be they from Kenya or Serbia or India, arrive in Canada hoping to benefit from the country’s need for doctors. Owing to their degree and, for most, their experience, they can skip medical school but must pass the same licensing exams as new Canadian graduates. Then they must go through our residency program before becoming certified doctors, but this step represents a major bottleneck. All Canadian medical school graduates are guaranteed a residency; IMGs must fight for a handful of these positions. If they don’t snag one, they must wait an entire year before reapplying. Many languish in stopgap jobs for years before finally setting foot inside a Canadian hospital.
This logjam is driving many of these would-be doctors southwards, because the American private system is better equipped to offer a wealth of residency positions. For communities like Midland, Ont., where family doctors are rare and the walk-in clinic recently closed, the idea that trained doctors are being turned away is justly frustrating. Wait times are a national problem and more doctors are needed. Turning away potential fast-track doctors seems ludicrous.
The question, however, is whose warts are worse? Is inefficiency a worthy price to pay for a system incapable of prioritizing anything but need? Or is expediency something to covet above the risk of monetizing patients, which in itself may not be endemic to privatization?After these two films, you can at least say you’re informed enough to make an intelligent decision and, hopefully, have a healthy discussion. Just don’t pay by the word.

Health Factory and The Big Wait are showing on Feb. 20 at 7 p.m. in H-110. Visit for more details.

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