A clinician's view of mixed health care in Quebec. Interview with Dr. Lawrence A. Stein, Radiologist. Interviewed by Samuel Lapalme-Remis for the MJM.

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MJM 2008 11(1):81-82 81Copyright © 2008 by MJM
FOCUS INTERVIEW
MJM: Please describe how your divide you practice
on a week-to-week basis.
Dr. Stein: I actually spend about 90% of my time in
the hospital system. I've done it that way since 1974.
Our group has always had a community clinic. I don't
like to use the word “private” clinic, it's a bit of a
misnomer because until about quite recently, patients
didn't have to pay for the imaging that was available at
theseclinics—chest
mammography, barium studies. These clinics started in
the late 1960's as an outlet for patients to get their
outpatient imaging done using their medicare card
without relying on an expensive hospital infrastructure.
Our group had such a clinic, as did radiologists at most
other hospitals.
Then about five or six years ago, these clinics started
to include CT, MRI, PET scanning and even nuclear
medicine. This was new in that these procedures weren't
covered by the medicare card and therefore patients had
to pay for that. The Quebec law is very clear regarding
radiological procedures;if it's not insured within a
hospital, you can charge for it outside a hospital. For
some other specialities, there's more of a grey zone.
MJM: What changed five or six years ago?
Dr. Stein: What changed is that CT, MRI and
ultrasound just became more used and everyone saw
that there was probably a group of patients that would
be able to afford or have insurance for these procedures,
and who would benefit from them.
At our clinic downtown, we offer everything we
offered since 1967, and since 2000 we've added to that
these advanced imaging procedures, so 60% of our
volume is medicare covered and 40% isn't. It's legal to
do this in Quebec, as it is in BC and Alberta. Also, in
x-rays,lumbar/spine,
Quebec, most private health-insurance programs that
people are enrolled in as an employment benefit cover
these kind of procedures, sometimes up to 100%, and
usually about 80%. This is unique to Quebec; if you
have a job, you probably have this kind of insurance.
MJM: What was the reaction when you introduced
these new services not covered by medicare?
Dr. Stein: Well, in 2000 we moved from a smaller
office where we had only offered the covered services
and opened a new and larger office where we offered
the advanced imaging as well.At the time we developed
and opened it, it was fairly unique. Had we done it five
years earlier, I think we would have had gotten a very
negative response, but at the time we actually did it we
got a fairly positive media response. The media were
very receptive.
MJM: What were some of the concerns that you
heard from the media?
Dr. Stein: The nature of the debate was what people
fear most when they hear about private health care, and
that's what happening south of us. They do not want the
American system in Canada. Quite frankly, I don't think
there are many Canadian doctors who want the
American system in Canada either, but that's what
patients fear. They see spiralling costs and a huge
volume of patients who can't afford health care in the
United States, and that's what they're bombarded with in
the media. Canadians are frightened about that. That's
the negative part. What Canadians don't always know is
how good the systems in Europe are, like in France,
Germany and the UK. These systems offer both
government-sponsored and alternative health care
working together. Canada is more like Europe overall
than like the US. Of course, pressure does need to be
maintained on the government to make sure that the
public system is properly supported. I've had career-
long commitment to and support for a strong, vibrant,
well-funded and properly staffed public health care
system where there is timely access to quality imaging
for all Canadians.
MJM: Per unit time, is it more profitable for a
*To whom correspondence should be addressed:
Lawrence Stein
Royal Victoria Hospital
Radiologist-in-Chief
687 Pine Avenue West
Montreal, Quebec
H3A 1A1
lawrence.stein@muhc.mcgill.ca
A clinician’s view of mixed health care in Quebec
Interview with Dr. Lawrence A. Stein, Radiologist
Interviewed by Samuel Lapalme-Remis for the MJM

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82
McGill Journal of Medicine
2008
radiologist to do a procedure inside or outside a
hospital?
Dr. Stein: It's just about the same. It's not to my
advantage or disadvantage to work at the clinic over the
hospital.
MJM: How would you describe the work you do at
the clinic?
Dr. Stein: As I mentioned before, I spend about 90%
of my time in the hospital; the clinic is a nice break for
me. The hospital is a very high-pressure, difficult, not
very efficient environment to work in. Going to the
clinic gives me a little bit of a respite.
We're doing very good imaging at the clinic. It's the
same community of patients and they're not using
hospital resources. Some people accused us at the
beginning of catering to the “worried well.” In fact, we
see more pathology per capita at the clinic than we do at
the hospital.
MJM: When a patient pays out of their own pocket,
as opposed to when they put down a card and don't have
to pay directly, do you sense any difference in the
interaction that you have with them?
Dr. Stein: No. Whether a patient is in the hospital or
in the clinic, they'll see no difference from me. I don't
think they perceive any difference.
MJM:
But the patients themselves, they don't
demand more?
Dr. Stein: They may be a little more demanding. They
will not tolerate waiting. If the appointment is at nine
o'clock, they expect to be seen at nine. In the hospital
you can often have a patient who has been waiting for a
considerable amount of time. That won't be tolerated at
the clinic.
It's interesting because that carries over to the patients
in the clinic who use their medicare card. They expect
to be taken care of on time too. It's just the environment.
MJM: How else does the population at the clinic
differ from that of the hospital?
Dr. Stein: Obviously, in the hospital we see sicker
patients, patients who are less ambulatory. Also, there's
two groups at the clinic, those who use their medicare
card and those who are paying or have insurance. Those
who are paying are probably a higher socio-economic
group.
MJM: Is that a concern of yours?
Dr. Stein: Yes and no. I look on that in two ways. The
first thing is, whose fault is it? If a patient needs a CT
scan and can't get it in an appropriate length of time, it's
the government's fault. So the fact that we're offering it
to some patients who can afford it or can get the
insurance, does it bother me? Yes, it bothers me; I'm
concerned about it. But it's the fault of the government
for not providing the resources that are necessary to deal
with the ageing population and higher technology. In
imaging, medicare is no longer sustainable. It may have
been good for 1967 to 1997, but it can't keep up with the
high cost in imaging. Something has to give, the money
has to come from somewhere.
MJM: Where would you hope that the money will
come from in the future?
Dr. Stein: I think that for the future, we have to allow
both parts, the state-supported and the alternative have
to be supported and allowed to thrive. And there may
even be situations where there's a link between the two.
The government may see that it's more worthwhile to
have things done in the clinic than in the hospital. But
right now they'd rather have the patient wait.
What I'm for is timely access to quality imaging. Full
stop. I fight every day of my life to get more resources
in the hospital. We don't have enough receptionists,
typists, technologists, radiologists. It's hard. Right now
we're capped by the number of radiologists, yet our
volume of work in hospital has increased. It's forcing us
all to work too hard. In the hospital, I'm often forced to
manage three patients at the same time when it should
be one patient at one time. It's hard to get a day's work
done without constant interruptions.
I don't have that at the clinic. At the clinic, 100% of
the time I'm attentive to what I'm doing and dealing
with the patient at hand.
MJM: Do you find this makes a big difference in
terms of the quality of care that you're able to provide?
Dr. Stein: You learn how to practice in the hospital.
You learn how to do it well. If you can't do it, you will
leave the hospital. I've had medical students ask me,
“how can you practice like that?”; they can see the
interruptions that I deal with. I just say, “you learn how
to do it.”
There are times where I have thought that each of us
is trying to do too much. I have to think that that is
prone to making errors.
MJM: What advice would you give a young
radiologist beginning their practice in Quebec?
Dr. Stein: I would say that the type of practice you
want is a combined hospital and outside-clinic practice.
We have a beautiful profession in that we can do both of
these things. The hospital allows us to do many things
you could never do in a clinic. You might be bored as a
young radiologist doing just an outside practice.
Lawrence A. Stein, MD, FRCPC, is Chief of Diagnostic Radiology at the Royal Victoria Hospital and Associate Professor
of Radiology at McGill University. He is a past President of the Canadian Association of Radiologists. Dr. Stein is on the
Board of Directors of the Westmount Square Imaging Centre, where he works as a practicing radiologist.