Is the Bank of Canada sufficiently transparent on monetary policy?

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Senator Diane Bellemare

QUOI Media

Canadians and the financial markets are often nervous on the day the Governor of the Bank of Canada announces the key interest rate. Not surprising, given the financial consequences for people’s wallets and the impact of this decision on the economy.

Do we really know how this decision is made?

Technically, the Governor of the Bank of Canada determines the key interest rate eight times a year in the context of monetary policy. He is supported by his Governing Council, made up of Deputy Governors whom he has chosen and who work for the Bank. In recent months, an external non-executive Deputy Governor has joined the committee.

But the Governor and his team could get it wrong, and the Bank Act is of no assistance.

The Bank Act was adopted in 1935 while the General Theory on Employment, Interest and Money of Lord Keynes was published in 1936. The Act was amended through time and revised in 1985. The preamble to the Bank’s Act was never changed and presents a list of objectives, of equal importance, with the intent, as the Act summarizes, “to promote the economic and financial welfare of Canada.” But the specific mandates for the Bank and for monetary policy have never been incorporated in the Act.

The Act gives the Governor full powers to act as he sees fit, without any transparency requirements.  It’s time we updated the Bank Act to reflect contemporary economic realities.

Since 1991, there is a monetary policy framework specified through a five-year agreement prepared by the Bank in agreement with the government through the Minister of Finance. This framework determines an inflation rate target without specifying the timeframe for achieving it. For the last thirty years, and renewed in December 2021, the agreement has targeted a two per cent year-on-year increase in the overall consumer price index (CPI).

This agreement is tabled in Parliament but is not subject to any parliamentary approval or accountability. The framework, which has no legal force, allows the Governor to raise the base interest rate as long as the overall CPI increases by more than two per cent. This is a simple rule for a problem that is not at all simple.

Indeed, inflation in the 21st Century has become a more complex issue than in previous generations. It is not mainly an excess demand problem. The climate crisis, political uncertainty, reversed globalization, demographic issues, all create supply shocks that will impact inflation. The target of two per cent may no longer be realistic.

Rising interest rates reduce with certainty consumption, investment, growth and employment. But it is not clear that it will reduce prices without creating a recession.

The Bank of Canada should not put aside its main purpose — the prosperity of Canadians — in the name of a risky strategy. Besides, there are alternatives.

Section 91 of the 1867 Constitution gives responsibility to the Canadian Parliament for making laws for the peace, order and good government of Canada in the areas of banking, the issue of paper, interest and legal tender. In short, from a legal standpoint, although the Bank Act gives the Governor and the Bank a great deal of autonomy, the Bank is not above Parliament. It must explain how its policy reduces inflation and at what cost.

Currently, the Governor explains his view in Parliamentary committees and to the media. And recently, the Bank started publishing the summary of the deliberations on the interest rate decision. Four times a year, it publishes a review of the general economic context. This is where the Bank of Canada’s transparency ends.

We do not know the economic and financial costs of the Bank of Canada’s strategy for individuals, businesses and governments. What are the redistributive effects, the effects on investment and productivity? What are the specific indicators on which decisions are based? What are the alternatives?

The Governor of the Bank of Canada has enormous powers compared to other central banks, which have a dual mandate (United States, Australia, New Zealand) that gives equal importance to price stability and full employment or have a monetary policy committee (United States, England, New Zealand) with external members that can propose alternative views.

If supply chains shocks are to become common, shouldn’t Canada’s monetary policy take them into account?  By repeatedly raising interest rates to bring inflation down, aren’t we compromising the future of the country by damaging business start-ups, housing construction and the climate transition, as well as tangible and intangible investment such as human capital?

The time has come to demand greater transparency on the real impact of short- and medium-term monetary policy on the Canadian economy and to amend the Bank Act.

Diane Bellemare is a Quebec Senator and an economist.

COVID-19 unleashed an ongoing crisis of delirium in hospitals

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Christina Reppas-Rindlisbacher, Nathan M. Stall and Paula A. Rochon

Older adults have borne the brunt of the COVID-19 pandemic. While Canadians aged 60 years and older make up only 20 per cent of the population, they account for 69.5 per cent of all COVID-19 hospitalizations, and most — 91.7 per cent — of all COVID-19 deaths.

One aspect of healthcare during the pandemic that has received considerably less attention is the failure of effective delirium care.

Delirium is a sudden and distressing state of confusion that occurs in up to half of hospitalized older people. It is usually triggered by a change in health, such as an infection or surgery, and is often short-lived but can sometimes cause long-term cognitive impairment leading to an increased risk of dementia.

Fortunately, delirium can be prevented or minimized using simple strategies. Within our own health practices, we have seen the effectiveness of promoting family caregiver presence, encouraging mobility and minimizing disruptions to eating, drinking and sleeping.  

In May of 2020, an opinion piece written by geriatrician Dr. Sharon Inouye in the New York Times, warned of an epidemic within the pandemic that was leaving many hospitalized older patients more vulnerable to delirium by abandoning many simple care approaches.  Unfortunately, she was right.

Our study recently published in JAMA Network Open showed that the fear of a delirium epidemic was realized. We found that during the first two years of the COVID-19 pandemic, older adults admitted to Ontario hospitals experienced more delirium and were discharged home with more sedating medications compared to before the pandemic.

Disruptions to delirium prevention care caused by the pandemic are in part to blame. A shortage of staff and volunteers, visitor restrictions and infection control rules created the perfect storm of less interaction with patients and fewer opportunities to use non-drug approaches for preventing and managing delirium.

Our study results are particularly alarming because we have made so much progress in delirium care over the last 30 years. Initiatives such as Senior Friendly hospitals, acute care of the elderly units and hospital elder life programs have flourished across Canada. In the three years preceding the pandemic, our study shows a clear trend of declining prescriptions of harmful and addictive sleep medicines given to older people after they left the hospital.

COVID-19 disrupted this hard-fought progress. Even two years after the onset of the pandemic, the number of new sedative prescriptions being prescribed out in hospitals has not returned to pre-pandemic levels.

So how do we reverse these dangerous trends?

It is likely that the fall and winter will bring a seasonal wave of viral illness such as influenza, RSV — and COVID-19, among others. Hospital and healthcare systems will soon be faced with decisions about visitor and volunteer policies in the face of viral outbreaks.

We can minimize rates of delirium by:

  1. Implementing policies centered on delivering dignified care, especially to older persons with cognitive impairment who cannot always advocate for themselves.
  • Renewing nationwide hospital efforts to mandate flexible hospital visitation and implement the simple and evidence-based care strategies needed to prevent and manage delirium.
  • Addressing national staffing shortages plaguing healthcare facilities across the country and redoubling our efforts to build and sustain senior-friendly healthcare environments.

Never again should sick patients with delirium be isolated from their family caregivers.

We must return to providing the standard of care for older people that reduces delirium and minimizes sedating drugs. We owe it to our aging population to provide the kind of humanistic care that helps older adults leave hospitals with their independence and cognition intact.

Dr. Reppas-Rindlisbacher is a geriatrician at Sinai Health and University Health Network and a PhD student at Women’s Age Lab at Women’s College Hospital.

Dr. Nathan Stall is a geriatrician and clinician scientist at Sinai Health and Women’s Age Lab at Women’s College Hospital.

Dr. Paula Rochon is a geriatrician and the founding director of Women’s Age Lab at Women’s College Hospital.

Reimagine aging in place

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Rachel Savage, QUOI Media

Both Canada and the United States are set to reach super-aged status in the coming decade, meaning over 20 per cent of the population will be over the age of 65.

Most will be older women with unique, and often misunderstood health needs. 

Many older adults are aging alone in the community even though we know being connected to family, friends, neighbors and communities are crucial for health and well-being.

Older adults are also at elevated risk for homelessness, something that can be exacerbated by financial disparity and social isolation, and a lack of access to and understanding of support services available.

We need to rethink how older adults age in the community.

Naturally Occurring Retirement Communities (or NORCs) offer a community-based solution to these pressing issues. NORCs are a geographical area, often a high-rise apartment building, that has become home to a concentration of 30 per cent or more older adults.

Offering enhanced supports within NORCs is a low-cost approach to support healthy aging that bridges connections between older adults and their communities and creates a space where external resources can have a bigger impact.

The Women’s Age Lab, along with partners, is embarking upon a six-year research study to support the implementation and evaluation of three enhanced NORC supportive service models across 10 sites in Ontario.

Examples of the interventions include on-site staff with specialized training and recreation coordination, mobile integrated health units to support distinct clinical needs, in-unit support for virtual care, and dedicated spaces for social and health programming.

We hope our initiative will help establish a model for others to follow that will improve the quality of lives of older adults, mostly women, as they age in place.

Rachel Savage, PhD is a Scientist at Women’s Age Lab and Women’s College Research Institute, Women’s College Hospital, an Adjunct Scientist at ICES, and an Assistant Professor at the Institute of Health Policy, Management and Evaluation, University of Toronto.

We need to rethink how we treat older women in healthcare.

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Paula Rochon, QUOI Media

Older adults need health care and social services that respond to their unique needs. For older women, however, research shows that this is not happening. They are often overlooked by the policy planners, researchers, and care providers whose decisions affect their well-being.

This is despite the fact that older women make up 55 per cent of the population of older adults in the United States and their numbers are expected to grow. In the coming decade, 20 per cent of the population in the U.S. and Canada will be over age 65, and most of them will be women. Older women may have different health and social needs than older men and fewer economic resources.

A new Women’s Age Lab is working to change the way society perceives and treats older women. Believed to be the first of its kind, the centre is using scientific research to address four under-studied areas that older women say are important to their health and well-being.

One is gendered ageism, which results in older women’s experiences and contributions being devalued.

Another is reimagining aging in place and in congregate care to ensure that the specific needs of older women are addressed whether they are living at home or in a long-term care facility.

A third focus is on researching ways to optimize drug treatments to reduce the incidence of adverse drug effects on older women.

The fourth area is on research to better understand loneliness in older women and develop strategies to foster social connection.

Through collaboration with healthcare providers, community organizations, and international experts, the lab is developing science-based health and social policy solutions to improve the lives of older women around the world.

Dr. Paula Rochon, MD, MPH, FCRPC, is Founding Director of Women’s Age Lab, a geriatrician and senior scientist at Women’s College Hospital and ICES in Toronto. She is a professor in the Department of Medicine at the University of Toronto (UofT) and is the inaugural RTOERO Chair in Geriatric Medicine at UofT.

Building a barrier-free benefit for people with disabilities

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Leonard Baker and Elizabeth Mulholland

It has been three years since the government first proposed the CDB to much fanfare in its 2020 Speech from the Throne. The good news is that Bill C-22 was supported by every political party in our government.  The bad news is that since the idea was first introduced, people with disabilities have fallen even further behind.

It’s time to get the money flowing.

The federal government must also fulfill its commitment to collaborate with the disability community in the design and delivery of the benefit to make it truly accessible and responsive to their needs. A Benefit without Barriers, a new report by March of Dimes Canada and Prosper Canada, can help.

Developed with people with disabilities and disability organizations, the report sets out principles and recommendations for the design and administration of the new benefit that are rooted in the hard-won experiences of those who have had to navigate Canada’s disability income support programs and are intimately familiar with the challenges these entail.

Their advice is designed to ensure that we turn a page on past mistakes and deliver a CDB that leaves no eligible person with disabilities behind. Their voices must be heard.

The process of applying for benefits is fraught with barriers that cause many applicants to give up in frustration. Even those who are ultimately successful may also pay a steep personal price.

Barriers include lack of awareness and information, as well as long, onerous and costly application processes that are hard to understand and navigate, and undermine the self-respect, dignity and mental health of many applicants. Individuals with disabilities often feel government application processes are largely designed to drive them away, rather than help them access benefits they are entitled to. They and their families and caregivers feel distrusted by their own government.

Applying for disability benefits is also costly, requiring applicants to pay out-of-pocket for assessments by healthcare providers and associated travel if they live in a community without someone who provides this service. Other barriers like lack of government-issued identification, difficulty finding a physician, and housing insecurity, further compound these challenges, leaving people feeling discouraged and defeated.

In addition, most people with disabilities lack access to one-on-one help to complete applications, appeal decisions, and self-advocate – all of which are often needed to successfully access benefits. 

Proving one’s disability can be exhausting and dehumanizing, especially when you have to do it over and over again to access different benefits – or to requalify for them, even when your disability is permanent and irreversible.

The new CDB needs to be better than this if it’s going to meet its goal of eliminating disability poverty. if its going to meet the government’s goal of eliminating disability poverty. It’s time for a humane, empathetic, and respectful benefit experience that, above all, does no harm to the people the CDB is intended to help. 

Success requires that government engage directly with people with disabilities as it designs the benefit and its administration to understand and actively address the risks associated with different options.

Only then can we be sure that the result will be a benefit experience that  fosters respect and dignity and treats people with disabilities as valued members of society.

We can start by automatically deeming anyone receiving provincial/territorial disability income support, CPP-Disability, the Disability Tax Credit or Veterans’ disability benefits to be eligible for the CDB. The government can also ensure that all CDB delivery staff are trained to the highest standard in how to communicate with and support CDB applicants and recipients.

Finally, the federal government can harmonize the CDB with other federal disability programs and work with its provincial and territorial counterparts to protect CDB income from claw backs. Our goal is to reduce poverty – not fill provincial/territorial coffers or simply move money between federal programs.

We can build a disability benefit without barriers and now is the time to do it. People with disabilities in Canada have waited long enough. Let’s get on with the job.

Leonard Baker is President and CEO of March of Dimes Canada.

Elizabeth Mulholland is CEO of Prosper Canada.

Time to speed up the pace of gender parity in politics

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by Susan Franceschet and Jennifer M. Piscopo

The Alberta election has come and gone. Two powerful women engaged in a closely fought battle, guaranteeing a woman premier no matter which party triumphed. Still, all-women contests in provincial elections are the exception, not the norm. 

Canada is falling further behind when it comes to women in politics, particularly in federal elections.

Canada ranks a pitiful 61st globally for women in parliament, far behind countries in Europe, Latin America and Africa.  How did we end up here?

Canadian women campaigned for the right to vote over more than three decades. Activists began organizing in 1876 but didn’t win voting rights until 1918. Indigenous people would wait several more decades.

Hard work and creativity were key. Women established provincial and national suffragist organizations. They gathered signatures on petitions. They staged mock parliaments to demonstrate their political knowledge and debate skills. And they were opposed and scorned at every turn.

But revisiting the suffragists’ playbook to demand parity in political representation might be a good idea. It’s been more than 100 years since Agnes Macphail became the first woman to be elected to parliament. Yet men still hold 70 per cent of seats in the House of Commons.

This underrepresentation matters, because when women hold political power, governments are much more likely to develop policies and prioritize spending on issues that affect them.

Consider that feminist organizing and lobbying ensured that gender equality was enshrined in the 1982 Charter of Rights and Freedoms. But having guarantees on paper was not enough.

Women also staged multiple protest marches to gain full reproductive rights and to call public attention to the ongoing problem of violence against women, including missing and murdered Indigenous girls and women.

The lesson keeps repeating itself: change doesn’t just happen. Those with political power don’t easily concede the needs or perspectives of those who are not represented.

Change happens when advocates mobilize others to join campaigns that call public – and then politicians’ – attention to problems of injustice, insecurity and inequality.

Other countries offer inspiration too.

In 1975, the women of Iceland went on strike. Instead of going to work or tending to their families, they took to the streets, paralyzing the country. Within a year, the government adopted the Gender Equality Act. Iceland has ranked number one in the world on gender equality for more than a dozen years.

More recently, on International Women’s Day in 2018, five million Spanish women workers staged a “feminist strike.” They marched in protest of the gender wage gap and ongoing violence against women, chanting slogans like “if women stop, the world stops.”

Today, Spanish women hold 42 per cent of parliamentary seats and a majority of cabinet posts. A proposed “Equal Representation Law” will preserve these gains. Spain already has a 40 per cent quota for women candidates, and the new law would elevate this quota to 50 per cent for parliament, cabinet, and boards of directors. 

Hard work and strategic alliances among women in Latin America also resulted in gender parity. Both Mexico and Argentina require parties to divide candidacies equally among men and women. And in Chile, women chanting “we are half, we want half” in the streets and in Congress resulted in the world’s first constitutional convention where women held exactly 50 per cent of the seats.

When women come together — especially across political lines — they get heard. In the U.S., men legislators accepted meetings with women lobbyists only when they realized that the women had mobilized constituents. And collaboration among women’s organizations was key in getting African parliaments to adopt gender quotas.

Of course, all these women faced hurdles when seeking quotas and parity. After all, securing the right to equal representation means that some men will have to stand down to make way.

But when women unite, they can win rights to political parity. A concerted campaign using the suffragists’ tactics — letter-writing, marches, and mock parliaments made up of women — would help to show that a status quo where men hold 70 per cent of seats in parliament is completely unacceptable.

Canadian women have come together and fought for basic rights before. To speed up the glacial pace of their political advancement, they probably need to do so again.

Susan Franceschet is Professor of Political Science at the University of Calgary, @sufranceschet. Jennifer M. Piscopo is Associate Professor of and Chair of Politics at Occidental College in Los Angeles, California, @Jennpiscopo.

New health deal needs transparent monitoring and evaluation process

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Gail Attara and Louise Binder

The Canadian healthcare system is letting us down. Cancer care is just one of the many disease areas harmed by the pandemic resulting in a lack of access to doctors, hospital beds and operating rooms. We need to do better.

Patients are waiting longer than ever to receive medically necessary treatments.

Specialist physicians surveyed report a median waiting time of 27.4 weeks between referral from a general practitioner and receipt of treatment. This is the longest wait time recorded in this survey’s history – and it is a whopping 195 per cent longer than wait times reported in 1993, when it was just 9.3 weeks.

Lengthy wait times result in more cancer patients dying. For all patients, wait times have serious consequences, such as increased pain, suffering and mental anguish. In many instances, wait times can result in poorer medical outcomes, transforming potentially reversible illnesses or injuries into chronic, irreversible conditions or even permanent disabilities.

Canada also has a doctor shortage.  Many Canadian families might not even be able to access primary care. A recent Canadian Medical Association Journal survey found that more than one in five Canadians – an estimated 6.5 million people – do not have access to a family physician or nurse practitioner.

The devastating human costs behind the statistics should concern all of us.

Some organizations have put hard numbers around this.  A report from All.Can Canada predicts  that disruptions to cancer diagnosis and care alone could lead to 21,247 more cancer deaths in Canada over the next decade, representing 355,173 years of lost life.

For breast cancer screening, a six-month interruption could lead to about 670 additional advanced breast cancers and 250 more breast cancer deaths. For colorectal cancer, a six-month delay in screening could increase colorectal cancer cases by about 2,200 with 960 more colorectal cancer deaths.

The good news is that the federal government has taken steps to try to ameliorate the problem. 

In February, the Prime Minister announced an investment of over $198 billion to help improve the healthcare system, noting that the public will judge whether this deal is a success. The four key areas of investment include family health services, health workers and reducing backlogs, mental health and substance use services, and modernizing the healthcare system.

As the leaders of a new grassroots collective of patients and patient group leaders, Patients for Accountable Healthcare, we will hold the federal, provincial and territorial First Ministers accountable for this deal.

Of concern, the agreements do not have a transparent monitoring and evaluation process built in, so the federal government should take immediate steps to track and determine the success of these investments. Eventually, the data plan that the Canadian Institute for Health Information (CIHI) is leading will provide some answers, but that is years away. 

Canadians deserve accountability now.  We need to know how this money is being spent and we need to see direct improvements in healthcare quality and access as a result.  

Our healthcare system must provide timely, equal, and equitable access to resilient, safe healthcare, respecting the Canada Health Act, while being accountable to the public.

If the government doesn’t monitor progress of the new deal, you can be sure Canadians will.

At Patients for Accountable Healthcare, the underlying values guiding our work are respect, meaningful and ethical engagement, accountability, transparency, timely access, excellence, capacity building and mentorship, social justice and safety. We should expect no less from our health system.

We are enlisting the help of patients in urban and rural and remote parts of the country, and from all ethnicities and backgrounds, to join us in monitoring and sharing findings from each jurisdiction.

We will not shy away from undertaking relevant education to patients, caregivers, and the public. We will monitor and evaluate the progress of this new deal using measurable, transparent, patient-oriented outcomes, to assess changes that adapt to the needs of the individual.

It would be most effective if the government invited us to the table. After all, healthcare is for the people.

Gail Attara is the Chief Executive Officer of the Gastrointestinal Society.  Louise Binder is a Health Policy Consultant with the Save Your Skin Foundation.  Together they lead Patients for Accountable Healthcare.

What 20 newcomers and immigration experts have to say about Canadian immigration and how to improve it

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Claudia Hepburn

QUOI Media 

When Dr. Binal Patel immigrated, she got a job assembling sandwiches in a fast-food restaurant to provide for her baby daughter. A dentist trained in India, Dr. Patel wondered how she was ever going to afford the fees for the Canadian dental exams and, if she did not, how she would ever regain her self-respect and provide adequately for her children in Canada.

Canada’s immigration numbers are rising year after year. During the 2021 census nearly one-in-four people identified as immigrants, the largest proportion of Canadian immigrants ever, and highest among G7 countries. A considerable portion of them, like Dr. Patel, are well-educated and highly skilled when they arrive.

According to a recent Bloomberg-Nanos poll, most Canadians agree, immigration is good for the Canadian economy. Many also acknowledge that, more than ever before, we need the talents and skills immigrants bring, especially in sectors like health care and IT.

There is less consensus on how well our immigration system is working or what needs to be done to improve it so that immigrants, like Dr. Patel, can integrate efficiently.

In the process of developing a new podcast, we asked 20 experts for their views on Canadian immigration, and for their ideas and initiatives to empower newcomers to integrate faster. Podcast contributors ranged from Canada’s Minister of Immigration, Refugees and Citizenship to business leaders concerned with productivity and labour supply, to immigrant sector CEOs working daily to support newcomer integration, and social entrepreneurs working to fix what they sometimes described as a broken system. We also captured the thoughtful insights of skilled newcomers, including Dr. Patel.

We heard creative perspectives on how to strengthen immigration to make it more equitable for newcomers. Arif Khimani, COO of Calgary-based IT staffing firm, MobSquad, talked about his company’s innovative approach. MobSquad identifies international tech professionals with the skills to match the needs of North America businesses. The company takes care of the immigration paperwork and find the immigrants lucrative roles so that they hit the ground running on arrival in Canada. Employers, immigrants and the economy all benefit.

Shamira Madhany, Deputy Executive Director and Managing Director for Canada of World Education Services (WES) reminded us that the speed of integration possible for IT talent needs to happen for healthcare professionals, too. Government, regulators and employers need to do a better job of ensuring that when internationally trained doctors, nurses and pharmacists choose Canada, we put them in a position to contribute their skills to our healthcare system as quickly as possible.

The perspectives shared with us were often inspiring but also, at times, dispiriting. Dr. Nnamdi Ndubuka, a public health physician and professor from Saskatchewan, shared his belief that Canada remains an incredible land of opportunity for newcomers. Meanwhile, Nick Noorani lamented the notion that in Toronto, “the best place to have a heart attack” was the back of an Uber, because of the number of internationally-trained doctors driving them. 

What resonated most for me from these conversations was the importance of creativity and cross-sector collaboration to address integration challenges for immigrants. As more countries around the globe experience population aging and skills shortages, that imperative is growing.

If Canada is serious about welcoming more immigrants and refugees each year, the status quo is not acceptable.

The next Dr. Ndbuka and Dr. Patel may decide the costs — in time and money — of integrating professionally in Canada are too high and choose one of the other countries working to fast-track the integration process for skilled professionals. Solving the challenges to integration our immigrants face will be key to our national prosperity, our healthcare system and Canada’s future.

Claudia Hepburn is CEO of Windmill Microlending, a national charity that empowers skilled immigrants and refugees to achieve economic prosperity through affordable loans and supports.

Why is being a patient a difficult pill to swallow?

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Harvey Max Chochinov

While being treated for an aggressive hematologic cancer, the former Head of a Department of Medicine at a large teaching hospital told me he wished he could hang a sign on his headboard, reading P-I-P: Previously-Important-Person. Despite extraordinary achievements, skills, credentials, and status, being a patient made him feel like an amalgam of parts; limbs, bodily fluids, organs, and orifices, all now suspect, some more wayward than others — and most, for his taste, far too readily on display.

Why is being a patient such a difficult pill to swallow?

Besides whatever concern or ailment brings you to seek medical care, there is something about the very nature of being a patient that deeply rankles. Whether trying to arrange a medical appointment, waiting to be seen in a clinic or hospital, or being examined under the watchful gaze of a healthcare provider, being a patient disrupts our sense of intactness, gnawing away like an existential termite.

At its core is the erosion of personhood and a feeling that identity is under attack, threatening to displace the essence of who we really are. 

It doesn’t have to be this way.

Our sense of who we are as people is highly individualized, based on personal experiences and relationships; affiliations, attitudes, culture, beliefs, abilities; opportunities and connections; inclinations and foibles. In other words, who you are as a person is highly specific and unique; never has there been, nor ever again, will there be one exactly like you. Being a patient, on the other hand, is based entirely on things that are generic.

Bodily parts are supposed to behave in exact and predicable ways, irrespective of who their owner happens to be. With all due respect, whether prince(cess) or pauper, poet or pilot, your bits and bobs are pretty much identical, in form and function, relative to everyone else’s.

And herein lies the problem with being a patient. The moment we enter the healthcare system, the focus of attention shifts from who we are, to the ailment or problem we are now facing. This shift puts identity in jeopardy.

A long-time dialysis nurse once told me she eventually came to think of patients as kidneys on legs. Patienthood eclipses personhood, casting a shadow that undermines the essence of who we are. This is bad for patients and their families; it is also bad for healthcare providers since emotional disconnection and objectification of patients is a harbinger for professional burnout.

One approach designed to decrease this kind of existential trauma is beginning to take hold, coined the Patient Dignity Question (PDQ). The PDQ asks patients, “What do I need to know about you as a person to take the best care of you possible”? This question forms the basis of a brief five-to-ten-minute conversation, focused on personhood. What matters to you? What are your core beliefs? What or who are you most worried about? What roles and relationships matter most?

In answering the PDQ, patients are being asked how they want to be seen or understood as a person by their healthcare team. These conversations are summarized into a few paragraphs, and with the patient’s approval, placed on their medical chart.

While mostly used in patients with serious illness, the PDQ is relevant across all of medicine.

Whether you are being seen for routine medical care, or find yourself moving towards the end of life, or somewhere in between, who you are and acknowledgement of who you are as a person, matters. And the things that people disclose by way of the PDQ profoundly change the way healthcare providers see them. I’m a survivor of childhood abuse. My son is battling cancer. I am afraid to die alone. I am a former department head of medicine.

During the COVID-19 pandemic, the daughter of a women on a ventilator in intensive care shared that her mother had survived the likely murder of her first child and was a spiritual leader in her community. She said that responding to the PDQ gave her a way of letting the healthcare team know that her mother “was no ordinary person.”

These kind of disclosures profoundly and forever change the healthcare provider’s lens, bringing an appreciation of who patients are as persons, above and beyond whatever ailment brought them to medical attention. This is good for healthcare providers, helping stave off emotional indifference that can lead to professional burnout, while restoring human connection with the potential for them to be more whole themselves.

It is also good for patients and families, ensuring that patienthood doesn’t overshadow personhood.

Being a patient is hard, especially when it undermines your feeling that you are still you. That, it turns out, is the hardest pill to swallow of all.

Dr. Harvey Max Chochinov is a distinguished professor of psychiatry at the University of Manitoba, and author of Dignity in Care: The Human Side of Medicine, recently published by Oxford University Press.

How much money does Canada’s health system really need?

Michael Wolfson

As usual, Canada’s provincial premiers have been demanding the federal government give them tens of billions more per year than they’ve just been offered for health care, while at the same time claiming (incorrectly) that health care is solely their jurisdiction. 

But if health care is solely a provincial responsibility, with taxing powers of their own, why do they demand massive federal cash transfers with no strings attached?  There are several possible reasons.

One is that health care costs are increasing too rapidly.  This is not a new argument.  In 1977, the federal government cut federal income taxes, giving “tax room” for the provinces to raise theirs by equal amounts, leaving overall taxes for Canadians the same, while shifting billions of dollars of revenue from federal to provincial treasuries – the infamous “tax point transfer.”  The provinces could thereby fund more of their health care from revenues growing in line with the economy.

But the provinces conveniently ignore this major reform and count only federal transfers in cash – then blame the federal government for being stingy, while avoiding raising their own taxes.

Of course, the federal government does have a national role in health care and needs to be accountable to Canadians — so why shouldn’t they attach strings to any additional cash transfers to the provinces, ensuring the funds are being used to improve health care and Canadians’ health?

Another reason provinces say they need more money is that health care is so expensive.  However, Canadians do not know whether the provinces are managing health care cost-effectively.  Indeed, evidence suggests not.

Internationally, Canada spends more per capita on health care than many other OECD countries, but performs poorly.

There are also worries about an aging population.  But many OECD countries both spend less on health care per capita than Canada, and already have more elderly populations.

So, the real solution is not throwing more federal money to the provinces.  Rather, it is overcoming decades-long blockages preventing meaningful health care reforms to contain costs and improve outcomes. 

Broadly speaking, there are four main areas of health care: hospitals, drugs, doctors and long-term care.  Long-term care has been seriously underfunded for decades, so the federal proposal to increase pay for personal support workers is most welcome. 

But within long-term care, there is a huge imbalance between home care and nursing homes. 

Provinces seem keen to build new nursing homes, while continuing to starve home care of funding.  This is not what Canadians want or need, nor is it cost effective.

Other than for long term care, there is no need for health care costs to rise dramatically over the coming decades – if there are appropriate structural reforms and better more integrated management. 

Of course, “you cannot manage what you can’t measure.”  Canada generally lacks data to understand one of the most important signals of inefficiency – “postal code medicine,” the often large variations across regions in numbers of surgeries and other kinds of health care, but these are inputs, not outcomes. 

Data to provide explanations why c-section rates and stenting after heart attacks can vary threefold across health regions are generally lacking.  In the rare cases where we have the data, there are health regions with no obvious benefit in terms of health outcomes – hence wasting money. 

So why do provinces continue to fund health care that has no benefits in terms of peoples’ health? This may take the form of inappropriate diagnostic imaging, unnecessary lab tests, repetitive doctor visits, overly expensive “me too” prescription drugs, excessive invasive surgeries, and doctors providing services more than adequately provided by less costly nurse practitioners in primary care teams. 

And why do hospitals have so many beds occupied by patients who could be more appropriately and less expensively cared for by long-term care? 

One reason is that too many Canadians are overly wowed by new drugs and diagnostics.  Putting public monies into home care and collecting and analyzing the data needed for cost-effective management of health care is not as sexy.

Let’s also “follow the money.”

Overall doctors may see their own incomes fall if funding were to be redirected to primary care teams. Hospital budgets would fall if some of their funding were reallocated to long-terms care.  Pharmaceutical firms would see declining profits if a national pharmacare program were implemented. 

Before more is spent on health care, Canadians need to insist on evidence that they are getting better value for the existing expenditures, and demand their politicians exercise the leadership to implement needed structural reforms. 

Michael Wolfson, PhD, is a former Assistant Chief Statistician at Statistics Canada and an adjunct professor in the faculties of medicine and law at the University of Ottawa.