By David Zitner, September 18, 2023
When it comes to healthcare regulation in Canada, there are glaring disparities that have real consequences for both patients and professionals. Canadians suffer when health services administrators remain unaccountable, and when clinicians are subjected to inconsistent and sometimes misguided regulatory decisions. As such, improving Canadian healthcare will require both an examination of the absence of regulation for health services administrators and a rethinking of the overzealous regulation of clinicians.
First, health service administrators in Canada operate without clear standards for their work as individuals, or a governing body to regulate those standards. While health services administrators in Canada are a part of the Canadian College of Health Leaders, the college is largely toothless, lacking any regulatory or disciplinary powers. Furthermore, the college fails to provide clear guidelines or standards for administrative practices. In layperson’s terms, Canada neglects to effectively oversee health service administrators.
This absence of oversight means that hospital administrators are unaccountable to any professional organization, with no obligation to report on the health outcomes achieved under their management. As a result, both the public and policymakers remain in the dark about the effectiveness of healthcare organizations. This inevitably contributes to the crisis of unreliable access to timely and high-quality care across the nation.
Our nationwide healthcare crisis did not happen through unforeseen or unforeseeable circumstances. In the years leading up to the crisis, health services administrators, working with government monopolies, introduced various policies that made primary care less appealing to medical graduates. Many primary care and specialized clinicians complain about the amount of time they spend having to comply with regulatory requirements that do not improve patient safety or outcomes. For example, many doctors complain about the amount of clinical time spent using inefficient, poorly chosen computerized health record systems. Such endless administrative tasks reduce the amount of time doctors can devote to treating patients and sharpening their clinical skills. Proper oversight of health service administrators through an empowered professional organization could create standardized administrative processes and eliminate such wasteful practices.
(Accreditation Canada does review the practices of most Canadian health organizations but has no role in assessing or disciplining individual administrators; nor does accreditation Canada inform the public about either overall results or errors that harmed patients.)
Forty years ago, the Federal, Provincial, and Territorial (FPT) Deputy Ministers committed to regularly report on access to care, waiting times and health outcomes. All three levels of governments have, collectively, failed to live up to this commitment. Reforming or replacing the Canadian College of Health Leaders to create a professional organization capable of both standardizing systems for health services administrators and disciplining incompetent administrators would enable the fulfillment of this commitment to report while simultaneously rooting out administrative inefficiencies.
Second, clinical health professionals are regulated by their provincial Colleges of Physicians and Nurses. However, this regulatory oversight is inconsistent, unpredictable, and increasingly ideological. These regulatory bodies turn a blind eye to certain clinical controversies while blatantly taking sides on others, even when the scientific evidence remains inconclusive.
One such example is the case of the over-performance of aggressive surgeries, like tonsil or uterine removals, which had sparked (now resolved) debates within the medical community. In my own practice, I encountered a patient facing a major blockage of both carotid arteries, necessitating a decision between aggressive surgical intervention and medical management including diet and exercise. The choice between specialists often depends on the patient’s preferred approach. Provincial colleges of physicians and surgeons, appropriately, refrain from offering an opinion or chastising doctors for their differing recommendations. Twelve years ago, my patient chose to see a doctor who recommended medical rather than surgical management and continues to enjoy a high quality of life.
Unfortunately, regulators do not adopt the same hands-off approach for other issues. Some doctors feel they risk sanctions from their provincial regulators when they advise parents against early aggressive interventions for people who prefer to look like the gender different from their genetic sex. The reason for the varying attitude towards these two issues, blockage of the carotid arteries and the desire to transition from one gender to another, seem ideological and not at all scientific. This inconsistent application of regulatory standards hampers doctors’ ability to give sound medical advice to patients in some situations.
Regrettably, some of these bodies have shown a tendency to make strong recommendations and attempt to enforce opinions in circumstances where there is a lack of credible scientific research, or consensus among the relevant experts. One striking example is the case of Amy Hamm, a British Columbia nurse who put up a billboard expressing support for J.K. Rowling’s views on sexual fluidity and transgender care. Most clinical guidelines related to gender identity emphasize the importance of listening to the youth’s voice; they do not place the same emphasis on acknowledging concerns about peer contagion and gender fluidity. This norm presents an ethical challenge for practitioners: pre-pubescent children lack the ability to foresee the long-term implications of aggressive, mostly irreversible, medical and surgical interventions, making informed consent difficult to obtain. For example, children almost certainly have little sense of what ‘reduced libido’ means.
Under the current regulations, anyone, including unlicensed medical doctors, can make suggestions on issues related to childhood gender identity and sexuality without fear of regulatory intrusion (people seeking their advice are also aware that the regulator cannot access information about their discussions). The World Professional Association for Transgender Health (WPATH) reports that a significant majority of prepubertal children experiencing gender dysphoria do not continue to experience it into adulthood. Accordingly, in the absence of college or regulatory intervention, many licensed doctors would recommend waiting until after puberty to evaluate the situation regarding gender appearance.
In the realm of childhood gender identity and sexuality, it appears that a strategy of “watchful waiting”, and “first do no harm” might be the most appropriate course of action, despite concerns about regulatory interference. This would allow for a more cautious and informed approach to medical interventions and enable youth to make decisions once they are mature enough to give informed consent.
The current state of healthcare regulation in Canada leaves much to be desired. The absence of accountability for health services administrators and inconsistent, sometimes unwarranted, regulation of clinicians highlights the need for a more balanced and data-driven approach to ensure the well-being of both patients and healthcare professionals.
Dr. David Zitner is a senior fellow at the Macdonald-Laurier Institute. He has participated at every level of Canadian health care including clinical practice, research, administration, governance and patient and professional education.