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The Canadian and American Health-Care Systems: The author replies
Letters The Canadian and American Health-Care Systems I enjoyed reading the article by Orford in the February 1991 issue of the Proceedings (pages 203 to 206) entitled "Reflections on the Canadian and American Health-Care Systems." The statement, "Patients are not allowed to consult specialists directly-they must be referred by a primary-care practitioner," however, is inaccurate, at least on the basis of procedures in the province of Manitoba. In Manitoba, specialists have choices. They can assess patients in consultation with other practitioners and charge a consultation fee, or they can examine patients directly and charge a fee for a routine office visit. At the Manitoba Clinic where I practice, a nurse screens and directs nonreferred patients to a specialist who deals with the patient's specific problem. Thus, patients receive medical treatment as necessary. Nonetheless, specialists at the Manitoba Clinic may limit their practice as they desire professionally.
1. 1. Mayba, M.D. Department of Bone & Joint Surgery Manitoba Clinic Winnipeg, Manitoba
In the article "Reflections on the Canadian and American Health-Care Systems" by Dr. Orford, which was published in the February 1991 issue of the Proceedings (pages 203 to 206), the author refers to the success of the Canadian system in "achieving measurable improvements in the health and wellbeing of the Canadian people." Subsequently in the article, however, Canadian practitioners are said to be at a disadvantage because of the restriction on available technology. The implication is that American practitioners have an advantage because of ready access to "high-tech" equipment. Ironically, however, despite the "disadvantages" borne by Canadian practitioners, the Canadian people fare much better than their American counterparts on the basis of factors such as life expectancy and infant mortality.' The standard medical response to the inability of the American health-care system to Mayo Clin Proc 66:760-761, 1991
improve these indicators substantially is that society cannot expect medicine to cure its ills. That statement is precisely the point-in the United States, people spend so much money for medical care that only a minimal amount is available for improved housing, education, and other "nonmedical" factors that might improve health tangentially even more than medical care. Ten years have elapsed since McDermott2 decried the lack of established indicators for measuring the personal effect of physician services on a society's health. Since then, considerable strides have been made in assessment of health status." Variables such as functional status and quality of life can be determined accurately. We need to analyze health status and traditional clinical variables routinely for facilitation of more optimal allocation of resources. The alternative is continued spending increases for medical care with minimal understanding of what services we receive. Harry P. Wetzler, M.D. Chanhassen, Minnesota
REFERENCES
1. National Center for Health Statistics: Health, United
States, 1989. Hyattsville, Maryland, Public Health Service, 1990, pp 116-117 2. McDermott W: Absenceofindicators ofthe influence of its physicians on a society'shealth. Am J Med 70:833843, 1981 3. Lohr KN (ed): Advances in health status assessment: conferenceproceedings. Med Care 27 (Suppl):Sl-S293, 1989
The author replies I appreciate Dr. Mayba's comments. In most provinces, when specialists examine patients directly they ate serving as primary-care practitioners and must charge the same fee as general practitioners. The exception is when they have previously encountered the same patient because of referral from a primarycare physician, if such a referral has been made within a specified period (usually 3 to 6 months). The administrative details vary somewhat from province to province, and Manitoba is more liberal than most. I completely agree with Dr. Wetzler's observations. In any society, relatively little is gained by providing 760
LETTERS
Mayo Clin Proc, July 1991, Vol 66
better medical care, but much is lost by providing inadequate or no medical care. Because 37 million people in the United States are underinsured and 17 million people are uninsured, it is not surprising that infant mortality rates are lower and that life expectancy is higher among Canadian residents than among US residents. To supplement their universal medical insurance system, the Canadian federal and provincial governments have recently been emphasizing health promotion through the strategies of fostering public participation, strengthening community health services, and coordinating healthful public policy.P Such an approach is likely to be more cost-effective for Canada in further improving the nation's health than emphasizing "high-tech" medical care, even though the latter substantially benefits individual patients. Robert R. Orford, M.D., C.M.
REFERENCES
1. EppHon J: Achieving health for all: a framework for health promotion. Health and Welfare Canada, 1986 2. EppHon J: The active health report-perspectives on Canada's health promotion survey. Health and Welfare Canada, 1987
The Inoue Balloon Catheter I read with interest the article on percutaneous mitral balloon valvuloplasty by Nishimura and colleagues in the March 1991 issue of the Proceedings (pages 276 to 282). I beg to differ with the authors about their description of the Inoue balloon catheter as "a new balloon catheter." The Inoue balloon catheter was the oldest such catheter used for nonoperative treatment of mitral stenosis by balloon dilation; its use was initially reported in 1984, 1 before any other type of balloon catheter had been designed. In fact, Inoue first used his balloon catheter clinically on June 3,1982, in a 33year-old man with severe rheumatic mitral stenosis.f Perhaps time will always be relative. What seems old to one person may seem new to another. Tsung O. Cheng, M.D. Division of Cardiology The George Washington University Medical Center Washington, DC
761
REFERENCES
1. Inoue K, Owaki T, Nakamura T, Kitamura F, Miyamoto N: Clinical application of transvenous mitral commissurotomy by a new balloon catheter. J Thorac Cardiovase Surg 87:394-402,1984 2. Inoue K, Hung J-S: Percutaneous transvenous mitral commissurotomy (PTMC): the Far East experience. In Textbook of Interventional Cardiology. Edited by EJ Topol. Philadelphia, WB Saunders Company, 1990, pp 887-899
The authors reply We appreciate the letter from Dr. Cheng and his appropriate comments about the Inoue balloon catheter. He is correct in pointing out that the Inoue balloon catheter is not a "new balloon catheter." Inoue and his associates have been using this balloon catheter for 9 years and have accumulated extensive experience in Japan, as was stated in our article. Our terminology "new balloon catheter" was in reference to the fact that this catheter has only recently become available to a few select medical centers in the United States on an investigational basis. This scenario has prevailed for many other catheterbased techniques, in which extensive experience was developed abroad before approval of the device for use in the United States. As is evident from the data in our article, we have been highly encouraged by the preliminary results with the Inoue balloon catheter. We wish to give due credit to Inoue and his colleagues for the development of this catheter and for their pioneering work in the establishment of mitral balloon valvuloplasty as a viable alternative to open-heart surgical procedures. Rick A. Nishimura, M.D. David R. Holmes, Jr., M.D. Guy S. Reeder, M.D.
The Editor welcomes letters and comments, particularly pertaining to recently published articles in the Proceedings. A letter should be no longer than 500 words and contain no more than 5 references. The letter should be signed. It is assumed that appropriate letters may be published, at the discretion of the Editor, unless the writer indicates otherwise. Receipt of letters will not be acknowledged. The Editor reserves the right to edit letters in accordance with Proceedings style and to abridge them if necessary.
1. 1. Mayba, M.D. Department of Bone & Joint Surgery Manitoba Clinic Winnipeg, Manitoba
In the article "Reflections on the Canadian and American Health-Care Systems" by Dr. Orford, which was published in the February 1991 issue of the Proceedings (pages 203 to 206), the author refers to the success of the Canadian system in "achieving measurable improvements in the health and wellbeing of the Canadian people." Subsequently in the article, however, Canadian practitioners are said to be at a disadvantage because of the restriction on available technology. The implication is that American practitioners have an advantage because of ready access to "high-tech" equipment. Ironically, however, despite the "disadvantages" borne by Canadian practitioners, the Canadian people fare much better than their American counterparts on the basis of factors such as life expectancy and infant mortality.' The standard medical response to the inability of the American health-care system to Mayo Clin Proc 66:760-761, 1991
improve these indicators substantially is that society cannot expect medicine to cure its ills. That statement is precisely the point-in the United States, people spend so much money for medical care that only a minimal amount is available for improved housing, education, and other "nonmedical" factors that might improve health tangentially even more than medical care. Ten years have elapsed since McDermott2 decried the lack of established indicators for measuring the personal effect of physician services on a society's health. Since then, considerable strides have been made in assessment of health status." Variables such as functional status and quality of life can be determined accurately. We need to analyze health status and traditional clinical variables routinely for facilitation of more optimal allocation of resources. The alternative is continued spending increases for medical care with minimal understanding of what services we receive. Harry P. Wetzler, M.D. Chanhassen, Minnesota
REFERENCES
1. National Center for Health Statistics: Health, United
States, 1989. Hyattsville, Maryland, Public Health Service, 1990, pp 116-117 2. McDermott W: Absenceofindicators ofthe influence of its physicians on a society'shealth. Am J Med 70:833843, 1981 3. Lohr KN (ed): Advances in health status assessment: conferenceproceedings. Med Care 27 (Suppl):Sl-S293, 1989
The author replies I appreciate Dr. Mayba's comments. In most provinces, when specialists examine patients directly they ate serving as primary-care practitioners and must charge the same fee as general practitioners. The exception is when they have previously encountered the same patient because of referral from a primarycare physician, if such a referral has been made within a specified period (usually 3 to 6 months). The administrative details vary somewhat from province to province, and Manitoba is more liberal than most. I completely agree with Dr. Wetzler's observations. In any society, relatively little is gained by providing 760
LETTERS
Mayo Clin Proc, July 1991, Vol 66
better medical care, but much is lost by providing inadequate or no medical care. Because 37 million people in the United States are underinsured and 17 million people are uninsured, it is not surprising that infant mortality rates are lower and that life expectancy is higher among Canadian residents than among US residents. To supplement their universal medical insurance system, the Canadian federal and provincial governments have recently been emphasizing health promotion through the strategies of fostering public participation, strengthening community health services, and coordinating healthful public policy.P Such an approach is likely to be more cost-effective for Canada in further improving the nation's health than emphasizing "high-tech" medical care, even though the latter substantially benefits individual patients. Robert R. Orford, M.D., C.M.
REFERENCES
1. EppHon J: Achieving health for all: a framework for health promotion. Health and Welfare Canada, 1986 2. EppHon J: The active health report-perspectives on Canada's health promotion survey. Health and Welfare Canada, 1987
The Inoue Balloon Catheter I read with interest the article on percutaneous mitral balloon valvuloplasty by Nishimura and colleagues in the March 1991 issue of the Proceedings (pages 276 to 282). I beg to differ with the authors about their description of the Inoue balloon catheter as "a new balloon catheter." The Inoue balloon catheter was the oldest such catheter used for nonoperative treatment of mitral stenosis by balloon dilation; its use was initially reported in 1984, 1 before any other type of balloon catheter had been designed. In fact, Inoue first used his balloon catheter clinically on June 3,1982, in a 33year-old man with severe rheumatic mitral stenosis.f Perhaps time will always be relative. What seems old to one person may seem new to another. Tsung O. Cheng, M.D. Division of Cardiology The George Washington University Medical Center Washington, DC
761
REFERENCES
1. Inoue K, Owaki T, Nakamura T, Kitamura F, Miyamoto N: Clinical application of transvenous mitral commissurotomy by a new balloon catheter. J Thorac Cardiovase Surg 87:394-402,1984 2. Inoue K, Hung J-S: Percutaneous transvenous mitral commissurotomy (PTMC): the Far East experience. In Textbook of Interventional Cardiology. Edited by EJ Topol. Philadelphia, WB Saunders Company, 1990, pp 887-899
The authors reply We appreciate the letter from Dr. Cheng and his appropriate comments about the Inoue balloon catheter. He is correct in pointing out that the Inoue balloon catheter is not a "new balloon catheter." Inoue and his associates have been using this balloon catheter for 9 years and have accumulated extensive experience in Japan, as was stated in our article. Our terminology "new balloon catheter" was in reference to the fact that this catheter has only recently become available to a few select medical centers in the United States on an investigational basis. This scenario has prevailed for many other catheterbased techniques, in which extensive experience was developed abroad before approval of the device for use in the United States. As is evident from the data in our article, we have been highly encouraged by the preliminary results with the Inoue balloon catheter. We wish to give due credit to Inoue and his colleagues for the development of this catheter and for their pioneering work in the establishment of mitral balloon valvuloplasty as a viable alternative to open-heart surgical procedures. Rick A. Nishimura, M.D. David R. Holmes, Jr., M.D. Guy S. Reeder, M.D.
The Editor welcomes letters and comments, particularly pertaining to recently published articles in the Proceedings. A letter should be no longer than 500 words and contain no more than 5 references. The letter should be signed. It is assumed that appropriate letters may be published, at the discretion of the Editor, unless the writer indicates otherwise. Receipt of letters will not be acknowledged. The Editor reserves the right to edit letters in accordance with Proceedings style and to abridge them if necessary.