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Brian RotenbergAll across Canada, provincial governments are grappling with ever growing healthcare demands in the face of shrinking resources. Our enviable publicly funded health system is now well into a downward spiral of unenviable disrepair. As patients are becoming more knowledgeable about their own care, and as doctors develop a wider array of options available to treat diseases, the costs are increasing.

The truth is, we can’t have it all. Both the physicians who deliver care, and the patients who receive it, need to start considering the concept of limited resources in our publicly funded healthcare system.

One of the main tenets of the Canada Health Act is that medically necessary care should be insured by public funds and that all related hospital or physician care should be paid for by the public system. This is the soul of the cherished notion of “free” healthcare that most Canadians hold so dearly.

But the tricky thing is that the Canada Health Act does not actually define what constitutes “medically necessary care.” This is left up to the individual health providers to determine on a case-by-case basis.

At first glance, it might seem easy to distinguish “medically necessary” care from optional care. If a patient is sick, then the treatment needed to fix the problem is intuitively considered necessary – the idea being that medical needs dictate what will be provided by the public system.

And in some circumstances, determining what is “medically necessary” is easy. Both patients and doctors could likely agree that if you have cancer, it needs medical treatment. If you have fractures from a car accident, they need to be fixed.

Likewise there are many other examples that most of us could agree fall into ‘optional’ care, such as laser eye surgery to remove the need for glasses, or cosmetic facial surgery – wants, not needs, that don’t merit public funding.

In between these examples, though, is a wide gray area where distinguishing need from want is not nearly so clear. Is fixing an annoying nasal blockage a need or a want? Is getting arthroscopy for a sore knee a need or a want? How about a patient who wants blood tests that aren’t medically indicated who is just curious?

Non-essential care is by no means limited to patient demand. There also exists a vast array of low-quality, or low-impact, health interventions initiated by doctors – and publicly funded. Many of these interventions are not supported by evidence. That blood test or chest x-ray your physician ordered for you before your elective operation? Very possibly unnecessary. The CT scan you had for pain in your lower back? The evidence says it will not improve your outcomes. The antibiotics you were prescribed for a persistent virus? Unnecessary, and they won’t work anyway.

Tests and treatments like these examples, and others, are not medically necessary and they are also costly to a struggling healthcare system. In fact, unnecessary tests can expose patients to harm because of false-positive rates. The “Choosing Wisely Canada” initiative spearheaded by the Canadian Medical Association is just beginning to explore the massive scope of unnecessary care, and the impact it has on patients and the health system.

Our contemporary free-for-all style of healthcare, a challenge on both sides of the medical consultation room, is totally unsustainable on the public purse.

Doctors need to start openly and directly considering the concept of medical necessity when talking with patients about tests or procedures. Patients, in turn, need to keep in mind that their healthcare is not “free,” and that many of their health-related complaints likely represent wants, rather than needs.

Working together we can salvage what is left of public healthcare in this country, but only if both groups promptly adopt a more realistic attitude toward medical necessity.

Brian Rotenberg is an Associate Professor in the Department of Otolaryngology – Head and Neck Surgery at Western University, London, Ontario.

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