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The Left Atrium
Contents
• Almost as good as it gets [PDF] • The loss of a friend [PDF] • Immortal jade [PDF] • Specialists [PDF] Almost as good as it gets
The efficient society: 
Is the adage that Canadians are merely unarmed Americans with health care true? What is it that accounts for Canada's ranking by the United Nations' Human Development Index as the best country in the world — well, now the third best — in which to live? According to professor of philosophy Joseph Heath, it is Canada's commitment to efficiency.
Aimed at the general public, Heath's book could be judged a lucid analysis of why Canada is (almost) as close to utopia as it gets or a misguided attempt to justify a hegemonic status quo. I suspect that such judgements will be made along ideologic lines (specifically, in accordance with whether one believes efficiency is maximized or minimized by government intervention). The allusion to ideology is relevant, for while Heath admits that efficiency as a central value is not an obvious choice, to examine the structure of our basic societal institutions is to see that traditional values based in religion and politics have been supplanted with an ethos of efficiency. Heath incorporates diverse philosophical arguments and cultural examples to demonstrate that the construction of many of our social institutions obtains maximal results while minimizing waste. Although he covers a wide assortment of interesting topics, ranging from advertising to globalization to morality, I will focus here on his treatment of health care. In Heath's view, the provision of universal health care insurance for Canadians has not resulted from a tenuous hybrid of capitalist and socialist economic arrangements, but from the realization that a relatively centralized mechanism for the distribution of health care services is more efficient than the free market. The welfare system, he writes, "is a perfectly logical arrangement — one that is designed to promote the overall efficiency of our economy." Comparing health care provision in the United States and Canada (i.e., private versus public insurance schemes), Heath argues that while both systems have inherent problems, the greatest level of well-being with respect to health is to be found in welfare, not market-based, economies. Private and public insurance schemes are quite similar; the biggest difference, of course, is that private insurers are corporations and public insurers are governments. Under both systems, users contribute a premium that gains them access to services. However, what makes these systems so expensive is the consumption by some users of more health care than is covered by their monetary contribution (i.e., premiums in the US, taxes in Canada).
Because the insurer will pay for most services provided, under both systems there is an incentive for physicians to bill as much as possible. Heath argues that single-payer systems organized by government greatly reduce bureaucratic overhead and the moral hazard of "free riders" who overuse services. In the US, the massive overhead costs of keeping track of every intervention (along with the associated billing and payment processes) remove resources that could be spent on care. In Canada, Heath argues, since the same agency is responsible for the billing and payment of services, there is no reason to divert resources toward, for instance, the micromanagement of how many prescriptions or sutures each patient receives. Heath also argues that by maintaining physicians on a fee schedule, as opposed to letting the market establish the price of services, the Canadian health care system keeps the amount of gross domestic product spent on health care significantly lower than in the US. Additionally, such a system eliminates adverse selection problems that deny insurance coverage to people who consume a greater-than-average share of health care. This is true to an extent. However, with the progressive delisting of medical services and the increasing prevalence of user fees in the Canadian health care system, the efficiency of the single-payer system is becoming more dilute. Moreover, recent data from the Organization for Economic Co-operation and Development shows that, in 1999, 29.4% of health care expenditures by Canadian patients were made in the private sector. I would contend that the debate surrounding health policy reform too often results in a forced choice between Canadian and American systems and ignores the fact that there are other options. In Sweden and Britain, for example, partnerships with private corporations and market-mediated mechanisms such as competition within public health care systems have resulted in greater efficiency (e.g., shorter waiting lists and reduction of operating costs). Heath does not deny that private and public systems both suffer from problems that affect efficiency. What he wants to argue is that there is no good reason to think that private-sector bureaucracies are more efficient than public-sector bureaucracies. Given the prospect of market failure and the possibility of uninsured individuals, we are better served by health care organized by big government than by big business. This is a well written and enjoyable book peppered with insightful (and quite humorous) anecdotes and observations from everyday life. Many will find Heath's ability to translate what could be difficult concepts into a popularist account helpful. Accessible yet thought-provoking, it provides an interesting account of how a secular value like efficiency can underpin a society. Many people will not share Heath's belief that the efficiency of a democratic welfare state provides Canadians with the best prospect for attaining the highest quality of life possible. However, Heath has certainly provided a plausible and coherent argument that deserves to be examined further. That being said, wherever one stands in relation to Heath's position, the existence of ever-growing waiting lists, crowded emergency rooms and other "funding crises" certainly challenges the belief that Canada's health care system is truly as efficient or as close to utopia as it gets.
Adrian M. Viens Contents
• Almost as good as it gets [PDF] • The loss of a friend [PDF] • Immortal jade [PDF] • Specialists [PDF] Tribute The loss of a friend
Later, in the auditorium, I faced the the exam with my classmates. It wasn't all that bad, I thought. But a knock at the door distracted me. I saw Vera, our student officer, motion to one of the invigilators, and then to the other, to come outside. I tried to stay focused. After a minute or so, the two invigilators re-emerged, only to look solemnly at the list of exam numbers and class members displayed by the overhead projector. I paused. I refocused once again. Then came the announcement: "Ladies and gentlemen, your attention for a second. Today, you must remain in the auditorium after completing the exam." Now my heart was racing. What did we do wrong this time? We must be in for another talking to. I had a creeping feeling in my stomach.
Vera returned before we had finished. One of the invigilators asked her to give us five more minutes. Tissues in hand, she retreated once more. My gut was still gnawing at me. I handed in my paper and asked to use the washroom. By the time I returned, several pastoral care workers were standing at the back of the auditorium. Something had happened. And now the dean of medicine was standing before us. It's not every day you get a visit from the dean. None of us could have imagined what was to come.
"Ladies and gentlemen, this morning your classmate, Gina Blundon, collapsed in her home. She was brought into emergency very early this morning but was unable to be resuscitated." Silence. Then tears. Then hugs. And more tears, sobs. Several others spoke to us about what had happened. A soft-spoken and obviously affected physician described his efforts. A counsellor told us about the resources we would have access to in the minutes, hours and days to come. We all remained. Even the the most stoic among us wept.
Our thoughts were of missing Gina. Of disbelief. How could this have happened? Why did it happen? How would we cope with this death? Our thoughts leapt to Kevin, her soulmate, and her parents. What must they be feeling? How could we extend ourselves to help a family few of us knew? That weekend we came together as a class on a number of occasions, to cry, to remember, to share our doubts and fears, our sadness and anxiety.
We attended the funeral wearing our name tags to show Gina's family that she had been respected by her classmates. She had been one of the most intelligent among us. She had entered medicine for the right reasons. She would have made a gifted doctor, for she would have cared so much for the patient, the person, who was before her. She would have been committed to each patient, each person. She would have made a colleague of whom to be proud.
What could come from Gina's death, a chance enounter with an aggressive viral myocarditis? Perhaps a realization of our own mortality. Perhaps a question: Were we living every day to the fullest? We thought of Gina's giant, famous smile, her colourful earrings and bright socks, her way of adding brightness to life with gestures as simple as tucking a small thank-you gift into notes and books she had borrowed from a friend. In such details she will be remembered; she will exist through us and in the doctors we become.
That morning before the exam I struggled to make the best of the time I had. We find comfort in knowing Gina made the best — indeed, more than she knew — with the time she had. May God grant her peace.
Andrew Healey
Contents
• Almost as good as it gets [PDF] • The loss of a friend [PDF] • Immortal jade [PDF] • Specialists [PDF] Lifeworks Immortal jade
To Confucius, jade was like a fine gentleman "esteemed by all under the sun." Indeed, as an exhibition recently on view at the Art Gallery of Hamilton attests, jade has been valued in China even more than gold and silver in the Western world. Jade, The Ultimate Treasure of Ancient China, presents some 120 jade artifacts: decorative, intricate work such as Sash Pendant with Dragonfly Carvings from the Song Dynasty (960–1279 CE), a detailed cup and saucer carved during the early Ming Dynasty (1368–1644 CE), and a shaman-like figure estimated to be from the Neolithic period (2600–200 BCE). The show is also a trove of historical detail. The visitor learns, for example, that jade craft in China attained its greatest glory and technical perfection during the reign of the Chinese Emperor Qian Long (1736–95 CE). A formidable patron of the arts, Qian Long went so far as to make jade his private property, declaring trade in jade illegal and punishable by death.
This exhibition revolves around a precious stone few of us know much about. Jade is not one stone but two: nephrite and jadeite. In their pure and most highly prized form, both varieties are white. The presence of other minerals such as iron and chromium gives jade its many hues, including the shade we call "jade green." Nephrite, considered the "true jade," is very resistant to fracture. Jadeite is more easily broken and produces a brilliant gleaming surface when polished. Both the mineralogic qualities of jade and its significance in Chinese culture explain the longevity and mystique of the ancient artifacts in this exhibition.
Jade as an exhibition is sensational, not only because of the age of the artifacts it contains, but because of the boundaries it straddles. Curated by Barry Till, curator of Asian Art at the Art Gallery of Greater Victoria, Jade is organized by the Canadian Foundation for the Preservation of Chinese Cultural and Historical Treasures (chaired by Nelly Ng, a Toronto physician) and the China Cultural Relics Coordination Centre. Jade successfully introduces aspects of Chinese history to an audience that, generally, has little exposure to this heritage. Jade is also the poster exhibition for the federal government's Canada Travelling Exhibition Indemnification program, the new jewel in the crown of the Department of Heritage.
Most of all, Jade crosses the boundaries between museum and gallery, artifact and art, craftsmanship and intellectual pursuit. Because of its social and anthropologic nature, Jade is an exhibition one might first expect to see at the Royal Ontario Museum or the Canadian Museum of Civilization (where it will be from May 8 to Sept. 2, 2002). Yet its touring schedule primarily involves art gallery stops (the Winnipeg Art Gallery, Sept. 6 to Jan. 6, 2002; the Edmonton Art Gallery, Jan. 25 to Mar. 24, 2002; and the National Gallery of Canada, Oct. 4 to Jan. 5, 2003). True, the exhibition contains artifacts — items representative of culture and tradition — but artifacts that are so painstakingly rendered that they cause us to question the distinction between art and craft. If we narrow the criteria to the media now traditional in Western art, we narrow the gallery doors to the exclusion of ancient arts that evolved separately from European influences.
As a stone, jade was believed to have protective and preservative qualities, warding off evil spirits and decay. The discovery of the tomb that contained both the princess and her husband, Prince Lui Sheng, considered one of the greatest archeological finds of the 20th century, confirmed academic speculation about ancient Chinese burial practices. Princess Douwan's suit looks like a green and gold mosaic suit of armour. Like the rest of this exhibition's pieces, the burial suit is accompanied by its own provocative anecdote: clearly, the jade did not protect this body from decomposition, but the porous rock does have absorptive capabilities. The accompanying taped narration speculates that the princess' DNA might be found intermixed with the fibrous rock that encased her for 2000 years. Maybe Douwan is immortal after all.
Sherri Telenko Contents
• Almost as good as it gets [PDF] • The loss of a friend [PDF] • Immortal jade [PDF] • Specialists [PDF] Room for a view Specialists
As a child, I remember watching intently my pediatrician's steel stethoscope as it swung back and forth on his neck, like a hypnotist's pendulum, lulling me into a near-panicky dread of its cold metallic shock on my skin. Then, just before he placed it on my chest — I would brace myself, every single time — he would miraculously remember to warm it up with his hands. And all fear would be forgotten.
Recently, I went to see a specialist for a recurrent problem that I have had for as long as I can remember. Roughly, our interaction went as follows: after we introduced ourselves to one another, I candidly told him exactly what the problem was, detailing it as any self-respecting medical student would. He acknowledged the problem and proceeded to ask me exactly how I would like things to be: essentially, what I thought he could do for me. After this, he took a moment to consider the problem, comb through the details and cut to the heart of the matter. He posed a few more questions and pondered further. Next, he offered his expert opinion and treatment plan and asked if I understood and agreed with his strategy. Finally, he proceeded with an extensive examination and the first treatment. Before I knew it, conversation was flowing freely, taking root in the frivolous banalities of small talk and blooming — an hour later — into the sharing of views and goals and, indeed, the sharing of many personal stories, as between friends. The power differential between the expert and his subject, and the disempowering act of sharing a personal concern with a stranger and putting myself "in his hands" seemed much easier now that the expert was also a person.
Before I left that day, I scheduled another haircut in six weeks and wondered, "Why can't doctors be like that?"
Samir Gupta
Copyright 2001 Canadian Medical Association or its licensors |
I rose at 6:30 to get a head start on cramming those last few arrhythmias. Grabbing a large coffee, I hid myself away for the remaining hours before the exam. I wanted to make the best of the time I had.
Nowadays, technology has "progressed": we do not have those cold stethoscopes any more. Instead, we have an armamentarium of much colder and darker things, like MRI machines, bronchoscopes and MRSA masks. Modern textbooks talk about things like blood samples, CT scans and MRIs as being "more dependable than the physical exam," but that's not the point. These tests are the idioms of a modern medical jargon that patients simply do not speak. Their language is the language of the physical exam, however pointless it may seem to us at times. In a strange metaphorical way, I feel that it is now my duty to warm up the stethoscope, somehow, through explanation and shared concern, to lessen the cold shock of the unnatural devices and procedures we now use to help our patients. The first step in achieving this is to understand that our notion of what constitutes caring for the patient does not necessarily (and probably does not usually) coincide with the patient's idea of what it is to be cared for.