Canada's publicly funded health-care system is meant to provide equal access to medical services for everyone – rich and poor alike. And for many Canadians, universal health coverage is a source of national pride. But a revealing study suggests that privileged individuals sometimes get special attention, while the less fortunate can still face discrimination.
The findings are based on a random sample of the offices of 375 primary-care providers – family physicians and general practitioners – in the Toronto area.
For the study, researchers phoned each office, posing either as a bank employee who recently moved to the city or a welfare recipient. In some cases, the researchers stated that they had chronic health problems such as diabetes and back pain. In other cases, they indicated they were in good health.
Following a standardized script, they asked if the doctor was accepting new patients and if could they book an appointment. Most of the calls were answered by support staff, and not the physicians. The results, published Monday in the Canadian Medical Association Journal, revealed a considerable number of offices seemed to favour the upper crust.
"We found that if you were of apparently high socio-economic status, you had a 23 per cent chance of getting an appointment, but if you were of apparently low socio-economic status that dropped to 14 per cent," said the senior author of the study, Dr. Stephen Hwang, a physician and researcher at St. Michael's Hospital in Toronto. That essentially means a privileged individual was 58 per cent more likely to see the doctor than a disadvantaged person.
A similar trend was evident when looking at whether the callers were offered either an appointment or a screening visit (basically a patient audition) or a spot on the waiting list: 37 per cent of the "high-status" callers were given one of these options, compared with only 24 per cent of low-status callers.
"Even in a system where doctors receive the same payment for every patient, regardless of the patient's income or occupation, we see evidence of discrimination against people of low socio-economic status," said Hwang.
"So you can't argue that physicians are selecting in favour of high-status patients because they are going to make more money," he added.
Instead, Hwang said, the study illustrates a much deeper societal problem. "It says something about human nature. Frankly, we are all prone to discriminate … and it is a tendency we need to guard against." He noted that physicians should be accepting new patients on a first-come, first-served basis. The Ontario College of Physicians and Surgeons, the provincial body that regulates Ontario doctors, has a specific policy that prohibits the pre-screening of patients – or so-called "cherry picking."
Although being offered a screening appointment is not as bad as an outright rejection, it's far from an ideal option. It simply provides another opportunity to weed out undesirables.
The study, however, did identify at least one egalitarian trend. Office staff had a tendency to give high priority to the prospective patients who suffered from chronic medical conditions. About 23 per cent of sick callers were offered appointments, compared to only 12 per cent of those identified as healthy individuals.
"Most of us would say that is appropriate," said Hwang. After all, ill patients are in greatest need of immediate care.
Hwang acknowledged that the study has its shortcoming. Ideally, every office would have received multiple calls from the researchers posing as individuals from different walks of life – including rich, poor, sick and healthy. But each office got only one call with the patient's personal characteristics randomly selected. That's because the researchers feared the receptionists might become suspicious if they received too many similar inquiries in a relatively short span of time.
Hwang thinks the findings are valid, although the researchers can't say, for sure, why the receptionists accepted some new patients and rejected others.
"We don't know what was in their minds – we can only speculate," said Hwang. "There are three possibilities. Support staff may have unconscious biases against people of low socio-economic status. They may have a conscious bias and are actually making a deliberate decision to say no to the patient. Or, the physicians may have instructed them to select certain kinds of patients," he explained.
"And we really don't know which of those factors are operating."
However, there is one unquestionable fact that emerged from the study: It's hard to find a general practitioner who is accepting new patients. The research team originally planned to poll 1,000 physician offices. But an initial stab at the list revealed a lot of these doctors aren't providing primary care. Instead, they specialize in weight loss, addictions, sports medicine or some other subdiscipline. That pared down the list to 568. In the end, the researchers were able to obtain responses from only 375 offices.
With so much demand and so little supply, it may not be surprising that some doctors' offices are tempted, consciously or unconsciously, to play favourites. And, of course, that does not bode well for people's ability to obtain care. "This impairs access to primary care and we don't think that is acceptable" said Hwang.