In spite of the B.C. Liberal government increasing funding for medicare, the wait lists have become untenable. The 鈥渃risis鈥� concerning colonoscopies is a current example. It will not help to simply throw more money at the system; I think there are some areas that demonstrate extravagance and wastefulness.
One example is that the Liberal government has introduced a potentially excellent program called 鈥淎 GP for Me.鈥� This impetus is likely to be lost because it has been minimally advertised. The Ministry of Health, at last, recognizes that the telephone is here to stay, and facilitates a modest fee ($15) for a telephone conversation between a participating family physician and a patient.
The theory is that this is more efficient for both the patient and the doctor, who could then use the extra time to see other patients and therefore is likely to be able to take more patients into his/her practice.
Patients need to know that this service is available, and to be encouraged to use it by requesting a followup telephone call instead of an office visit to review results, thus saving the system ($34.63 - $15 =) $19.63, in the case of a 60-year-old patient.
Another area of great concern and wastefulness is repeated cholesterol testing. Cholesterol readings are an indicator of relative cardiovascular risk in any individual patient. Cholesterol, however, does not, in itself, cause cardiovascular disease.
An analogy is that a person with red hair is at increased risk of skin cancer. Would cutting this person鈥檚 hair off or even dying it black reduce the risk of skin cancer? Of course not, and reducing cholesterol alone will not protect the patient from cardiovascular disease.
The person with the skin problem should be advised to avoid the midday summer sun, be very careful about using sunscreen, preferably wear clothing as protection and get the skin inspected regularly for potential melanomas.
The patient with high cholesterol should be encouraged to quit smoking, which is even more hazardous to him/her, follow a Mediterranean-type diet (high fibre and low saturated fats), exercise and keep the body at an ideal weight.
Measuring the cholesterol every year or more frequently will not affect the management. It is reasonable to check the cholesterol once to assess the relative risk. Patients with higher cholesterol should be strongly urged to follow the measures mentioned in the previous paragraph. Further measurements of the cholesterol have no value. If the cholesterol fell precipitously or did not change at all, the lifestyle measures should be kept in place.
It is argued that serial cholesterol levels are needed the help adjust the dose of cholesterol-lowering drugs known as statins. Though these medications reduce cholesterol levels, probably their primary effect is anti-inflammatory and exerting beneficial effect on the damaged lining of arterial blood vessels.
I like the reasonable argument that the dose of the statin drug should depend upon the degree of potential vascular damage in the patient, and not on the serum cholesterol level. A relatively healthy young man with an uncomplicated heart attack would need a relatively small dose, while an overweight, diabetic smoker would need as high a dose as can be tolerated.
Each cholesterol test costs $22.48. The cost of a colonoscopy is a $230.62 physician鈥檚 fee, plus the cost of nursing staff and maintaining the apparatus. Allowing 50 per cent for these overheads, the total cost is probably $350. So avoiding 15 lipid-profile investigations will free funding for one more colonoscopy. Seventeen telephone rather than office consultations would also pay for a colonoscopy.
There are ways we can all do our bit to help this overstressed system. Patients can seek help from their family physician first, and encourage telephone followup visits. Physicians should embrace this program with enthusiasm, as well as ensuring that they are accessible through a generous supply of same-day appointments for urgent and semi-urgent problems.
Patients, ask yourself if knowing your cholesterol level will make any difference to your long-term health choices.
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Dr. Chris Pengilly is in family practice in Saanich.
