Healthcare Quarterly

Healthcare Quarterly 8(1) January 2005 : 72-73.doi:10.12927/hcq..16953
Book Review

Patients First by Terrence Montague

Chris C. Carruthers


Dr. Terrence Montague has had experience as a physician in the military, in academic medicine and more recently with a large pharmaceutical company. His experience provides him with significant insight into the challenges of the Canadian Health system.
The important message in his book is to close the healthcare gap. The gap refers to what is known as "best medical practice" compared to what the patient actually receives. As he demonstrates, there is a large gap between these two outcomes. Recognizing that the present healthcare system approaches the financial challenge by rationing, Dr. Montague distinctly demonstrates that population health could be dramatically improved if we could achieve a high correlation between best practices and the care provided.

There are several reasons for the care gap, and they include poor diagnosis (12%), poor prescription (31%), poor compliance (33%) and poor access (22%). He recognizes that there are many influences affecting these gaps. His solution is to engage the stakeholders in the debate, to share knowledge more effectively and to work toward common goals. It is recognized that the care gap is greater in older patients.

The greatest challenge in the prescription gap he indicates is the under treatment of high-risk patients.

Many factors contribute to the compliance gap, including both the patient and the physician. The solution here is a combination of education, measurement, feed back and financial incentives. The interventions should be applied to patients, physicians and pharmacists. A strong patient provider interaction will improve success.

Within access, the author discusses the amount of spending in healthcare today. He suggests, quite rightly, that in the future more health costs in Canada will be shifted to individuals and corporations. He sees the United States moving towards more public funding and Canada heading towards more private funding with the two systems becoming more similar in the future.

To gain appropriate value for resources, any new health innovation should prove its worth in significantly improving population health. The challenge is our ability to afford new and innovative care that will improve the population health, particularly without significantly raising the cost to taxpayers (i.e., increased taxes). Already Canadians direct a large amount of their taxes to healthcare. There is probably not much room for increased taxation. As such, we must use our existing resources effectively.

Under the topic, "Aging Gorilla," the author demonstrates the more significant care gap in the elderly and particularly women. This is even more important as many diseases once thought acute are now chronic (e.g., certain cancers). Again, the causes are probably many, but physicians' perceptions on managing older patients are a key variable. Physicians must recognize that our population is aging, but remaining more active into later years. This population deserves appropriate care based on physiological, not chronological age.

The author outlines the key issue of patient health management or, more commonly, disease management. This approach is to look at the management of a disease from the population perspective. Implementing appropriate research on the population (e.g., randomized clinical trails) to identify the extent of the disease and its complications, and studying the outcome of interventions to manage the disease. Successful interventions are then implemented with the ultimate goal to minimize the care gap using scientific information.

The author provides several examples of large research studies in Canada that have lead to better disease management. One such study led to improving cardiovascular outcomes in Nova Scotia. The author suggests that many similar large population studies could be established for the many chronic diseases that exist. These studies would be a partnership of patients, governments and the private sector.

A key aspect of this approach is patient empowerment.

The author suggests that physicians during their education should be taught more about the management of the health system. This I also strongly support.

The author's vision and suggestions for addressing the care gap are excellent. He has a vision on how our healthcare system should change. But will politicians and others act on or dismiss these suggestions?

In Ontario, the recent agreement on physician payment between the Ontario Medical Association and the Ministry of Health included financial incentives to reduce over prescribing by physicians. This incentive was met with overwhelming negative press. Also, across Canada there are varying degrees of enthusiasm for public/private partnerships.

A challenge, not addressed by the author, is an evolving multicultural society. Addressing the variables leading to a care gap are an even greater challenge with many minority groups, where language and cultural beliefs may be a barrier to early successes.

Implementing many of these ideas, though necessary, will be costly. It would have been valuable for the author to have addressed this challenge within the context of current health resources.

This is an excellent book that demonstrates the problem of the care gap and the steps, many very easy, that could be taken to improve population health. This would provide improved care and outcomes within our present resources. Dr. Montague advocates a proven approach to change our health system so that we spend our resources more wisely. The outcome depends on politicians listening and acting on his recommendations. Unfortunately, politicians' track record in support of change is not good.

About the Author(s)

Chris C. Carruthers is Chief of Staff of the Ottawa Hospital and founding President of the Canadian Society of Physician Executives.


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