As a customer base, the poor are often stereotyped: They’re never on time and often have untreated mental health problems. Some are addicts or have spent time in prison. They’re so desperate that they constantly are trying to get something more out of you.
It might seem inconceivable this line of reasoning would enter into a medical practice, but don’t be so sure.
“In London (Ont.) a lot of doctors interview (prospective patients) and they only accept healthy, rich patients. I’m not joking,” London family doctor Ramona Coelho recently told The Catholic Register. “The reason I carry such a heavy, marginalized group — and it’s totally unprofessional — is that doctors will refuse patients. Why? Because they can make tons of money if they can have 6,000 healthy patients and work 30 hours (a week).”
The College of Physicians and Surgeons of Ontario (CPSO) has long had a policy against cherry-picking patients and has labelled the screening interviews for new patients “not appropriate.” A new draft policy attempts to strengthen the policy with clearer, more direct language, but there are worries that it doesn’t go far enough to address medical access for the poor.
“Physicians must employ the first-come, first-served approach,” says the new policy, which will likely come up for a vote at the CPSO board in May.
Coelho’s observations about some of her colleagues have been backed up in a 2013 study by the Centre for Research on Inner City Health at Toronto’s St. Michael’s Hospital.
St. Mike’s researchers had volunteers call doctors’ offices to try to book an appointment. The volunteers were given a script that hinted about their socio-economic status — some said they were bank managers, others that they were waiting for a welfare cheque. The better-off patients landed appointments 22.6 per cent of the time, compared to 14.3 per cent for the poor patients. The difference comes despite the fact OHIP pays doctors exactly the same amount for seeing a patient on welfare as it pays for seeing a bank manager.
The CPSO’s new policy is driven largely by Ontario’s human rights code, which specifically prohibits discrimination.
“They’re trying for fairness. They have their values of transparency and service and so on,” said Catholic bioethicist Bridget Campion. “That (first-come, first-served) sounds like a really good way of doing it, except it kind of isn’t.”
If the goal is to ensure equal access to primary health care, telling doctors to take whoever shows up in the waiting room first will still mean that more rich people have family doctors and more poor people will get their health care in emergency rooms and walk-in clinics, said Campion. Registering with a family doctor requires planning and stability. You have to have an address, a phone number and the ability to show up for appointments.
“We cannot underestimate the disorganization that comes with poverty, that the person is simply overwhelmed by her or his circumstances,” said Campion.
Catholic ethical principles would dictate that doctors have to find ways to favour poorer, sicker and more disadvantaged patients, said Campion.
“We have in our social justice tradition the idea of the preferential option for the poor and oppressed,” Campion said.
Dr. Fok-Han Leung, a family doctor at St. Michael’s Hospital and an assistant professor at the University of Toronto, understands why the CPSO needs a straight-forward rule to prevent cherry picking. But he rejects the idea it will result in better delivery of health care to those who need it most.
“The more privileged you are the more likely you are to know who is accepting new patients and to be able to attend these appointments on time,” he said. “Outpatient care is very doctor-centred. We have patients come to our office during our time. The folks with significant mental health problems, the working poor, the ones with significant disability, the ones with immobility — they are all going to be disadvantaged in this first-come, first-served model.”
The CPSO can set minimum standards, but rules are no substitute for the idea that practicing medicine is a vocation and a sacred trust. “Regulatory bodies really work on that policy and legal side, which is going to be fairly mechanistic. That’s the way it has to be,” Leung said.
“Taking on marginalized, complex patients is going to hands down be more work and thereby be less financially rewarding. What then is going to be the impetus to do this?”
The CPSO policy has to be concerned with “avoiding a violation of justice,” said Catholic bioethicist John Zamiska, but it can’t stop there.
“I could see the Catholic view including this (CPSO rule) but also going further by using it as a reflective guide for the physician as to why he chose the profession in the first place and why she or he is conscientious of the goals of continued, reflective, compassionate care,” Zamiska wrote in an email. “Otherwise, the profession can degrade to a ‘going through the motions’ and persons become viewed as objects or means to the end of an efficient business operation.”
This notion of a vocation in medicine isn’t something that requires some heroic, impossible ideal imposed exclusively on doctors. The ethics of health care are built on a simple, basic human vocation to care, said Campion.
“Honestly, when we forget care in health care we don’t have health care anymore,” said Campion. “We have an industry of some kind. And everybody suffers, including the care providers.”
Coelho is keenly aware how important the care ethic is to her practice. “As a family doctor, I get to build relationships with people over years,” she said.
“I love the relationships. Because my patients are sicker, I see them more frequently. I know them very well. I usually know everything about their lives and their families. Often they bring their grandkids to see me. I think, I really love that. That’s a big part of my vocation as a doctor.”