History of Medicine, Medicalization & Doctors - (up to 252) Flashcards
earliest type of society
hunting & gathering band
hunting & gathering band
small society
30-50 people:
adults & children less than 100 people
Describe early society (hunting&gathering band)
society of equality
- no rich or poor b/c no possessions
- Nomadic
Had a CHIEF that formalized decisions of the tribe Gender equality
gender division of labor
had medicine women
Gender Inequality taught by?
“white man”
How does early hunter gather society relate to healthcare?
healthcare became women’s work b/c it evolved as an extension of women’s 2 basic roles
womens B
1) childcare
2) gathering
Describe womens 2 basic roles and how they relate to healthcare
1) childcare: involves HC, picked up skills, human biology became women’s domain, begins with childbirth
2) gathering - plants
medicine came from herbs & plants (an extension of cooking)
How was the Human Body viewed differently by
a) Modern Male Medicine
b) Tribal Societies
a) mechanical model of human body
b) balance of nature - more holistic
Describe Tribal Societies view of the human body
strong sense of ecology
people were a part of nature
had to maintain balance of nature
Describe the importance of the Balance of Nature to Tribal Societies & its relationship to HC
if screwed up the people would suffer eventually nature was understood in spiritual terms so HC was about getting in touch with spirit world
Deity
Goddess - idea of nature as a whole
supernatural being that is the embodiment of **nature **
Why is the Deity female?
Deity had created the world & women are givers of life
therefore it is only logical that she is female
Central Concept of Healthcare in Tribal Societies
Healthy vs. Sick
Balance
sick = out of balance with goddess
healing = restoring balance
In Tribal Societies, HC was tied closely to?
**Spiritualism **→ became religion
Describe the role of the Medicine Women
doctor + spiritual leader (priestess)
- expert on herbal medicine & healthcare
- interpreted goddess’s wishes
Did men play a role in HC?
yes → Shaman (witch doctor)
Shaman
- roles
male “witch doctor”
- led men into rituals & prayers before war/hunting = - boosted social solidarity (unity)
What caused the change of societies from HUNTER-GATHERER to AGRICULTURAL
couldn’t feed increasing popn
developed agriculture
**- ** allowed popn to expand b/c it allowed for storable wealth
Where did Agriculture begin?
in Middle East & Africa
Problems with Agricultural society
led to
- social inequality
- class inequality
- gender inequality
How did the shift to Agricultural society lead to social inequality?
agricultural society developed into slave empires
**- **prisoners of war became slaves
rise of CLASS INEQUALITY + aristocracy (military) > peasants > slaves
How did the shift to Agricultural society bring about gender inequality?
increasing importance of army increased the importance of men
- men took over priestesses
replaced by male priest
men took over HC
After shift to Agricultural Society, men took over (3)
- Politics
- HC
- economics
Health in Ancient Greece
healing = women’s work
Hyglia - greek goddess of healing
Over time Greek society become more?
militaristic
**Hyglia **→ Apollo (male god)
male medicine dominated female medicine
Hippocrates
ancient greek physician
- made Hippocratic Oath
saw his techniques as restoring balance
Hippocratic Oath
religious oath
**- **do not harm
- do not betray patients trust
- contains prohibitions about sexual contact with patients (the fact that this clause was introduced shows it was meant for men)
The main goal of Hippocrates
to seperate medicine & religion for the first time
Greek Physicians made significant advances in…
anatomy & medicine
The significant advances made by Greek Physicians were brought together by? when?
Galen → 2nd Century
Galen
summarized what others had learned before him
- published an anatomy text in **2nd Century AD - **
developed model of human body
Galens model of the human body
body is composed of specialized organs each performing specific functions & working together
Galen’s text was the authority on human anatomy until late 16th century despite..
never having dissected a human cadaver
-based on dissection of apes & pigs
Early Christianity & human dissection
4th Century: Catholic Church forbade human dissection & anatomical examinations
- believed people were resurrected on judgement day and this could not occur if body was cut into pieces
- remained this way throughout Medieval Europe
After Greece & Rome Collapsed in 4th Century…What happened to the progress of science & medicine?
science & medicine came to a halt
Church decreed that health was determined by spiritual things (not physical)
- tied to religion once again
Male medicine after collapse of Greece & Rome
beyond prayer, reduced to military medicine
- bandage wounds & pray they live
Age of Feudalism
quiet resurgence of female medicine
- every village came to have medicine women (old religion of goddess never really died out)
- acted as midwife, healer (herbal meds) & spiritual leader
16th Century: Europe
feudalism → CAPITALISM
religion threatened by rise of science
16th Century: Italy
Renaissance - rebirth of knowledge before Middle Ages
- tried to resurrect scientific approach
Galileo defied Church with his astronomical revelations which undermined Church’s teaching
- was forced to recant
Leonardo Davinci
one of the first to defy Church’s ban on human dissection
(2) things that Challenged the Church in 16th Century
science
Prodestantism
Germany - Martin Luther
German Preacher
said Catholic Church had fallen away from path of Christ b/c they were all about wealth & power
How did the Church maintain its Authority?
found a Scapegoat that only the Church could save Europe from (pushed womans status down)
How did the Church use a scapegoat to maintain its Authority?
began witch hunts lasted through 16th & 17th Century (200+ years)
witches = medicine women
- were believed to be in league with the devil
The Inquisition
reign of terror
- went from town to town & tortured/burned at stake/killed witches
~100,000 to 1 million killed
mostly peasant women
- blamed womens for societies problems
What was the beginning of Society blaming women for everything?
Eve → blamed for taking the forbidden fruit
How long did the Catholic Church remain as the primary authority in Europe?
over 200 years after beginning of witch hunts
Mid-18th Century: ____Revolution
Industrial Revolution
Industrial Revolution
people began to leave villages for big cities
- witch hunts died out
Since 1960’s: Resurgence of _____
Wicca → religion
In the late 16th/17th Century, what emerged again?
Male medicine
What kind of new healthcare emerged from 17th Century onward?
male dominated
- increasingly based on science not spirituality chemical meds replaced herbal
How did the shift from **Agricultural to Industrial **affect HC?
more industrial type of HC
- based on dif model of health & human body
Industrial society → model of human body
Rene Descartes
rediscovered & updated Galen’s model → MECHANICAL model of body
Mechanical Model of Human Body
human body is like a machine
simple parts with simple functions
- could be taken apart & put back together
Basis of modern surgery (2)
cuts‘n’ chemicals (surgery & pharmaceuticals)
Descartes model lead to?
new approach of medicine → called Allopathic Medicine
Allopathic Medicine
based on isolating specific problem & dealing with it
aka specific aetiology
- more intrusive
widely accepted bc it showed results
Allopathic Medicine lead to?
specialization → localized pathology
**- **opposite of female **holistic approach **
Men → specialize /compartmentalize where as women…
Women → look at human body as a whole
Mechanical model lead to new medical technology such as?
microscope
the microscope lead to the rise of (2)
vaccination (18th Century) - Edward Jenner
germs/other microorganisms (19th Century) - Louis Pasteur
Modern Medicine
isolate from environment
- away from psychological support
- objective
ignores social context
**- ** downplays role of emotional support
Female vs. Male
care vs. cure
What types of problems do
a) men’s approach
b) women’s approach work best for?
a) acute
b) chronic
Historical Development of Modern Healthcare (sociological approach)
born not just from technological advancements but from social struggle between different groups that had different ideas of how it should be run
18th & 19th Century- Power struggle
Homeopathy vs. Mechanical Model
Barber-surgeons
through 17th & 18th Century
How did Academics gradually transform Modern Medicine?
**12th Century- Bologna **
North Italy Universities → defied ban on human dissection
- gradually brought science & medicine together
Francis Bacon
Founded Royal Society in 17th Century Britian - promoted development of all empirical sciences including anatomy
With the help of the Royal Society, what was formed?
Guild of Surgeons (18th Century)
- not just barbers
- surgeons given more respect
Ivan Illach
1970s
one of the 1st to question role of doctors
- found that mortality rates declined long before introduction of drugs & scientific techniques (although antibiotics were 1st developed in 1920s, over 90% of decline of disease rate had happened before antibiotics were available in 1940s/50s)
Ivan Illach & Iatrogenesis
- (3) sorts of **Iatrogenesis **
- argues that contemporary medicine is iatrogenic - **creates disease & illness even as it provides medical assistance
**1) Clinical - **pain/sickness/death result from provision of medical care (unneccessary procedures, Thalidomide)
**2) Social - **health policies reinforce industrial organization which generates dependancy & ill health
**3) Structural - **loss of individual autonomy & creation of dependancy
(2) things really improved peoples health:
improvements in
1) nutrition - world trade
sanitation - sewers
When French & British came to Canada.. early physicians were?
ship doctors
War between France & Britian
Britian took over Fur Trade from France but only **after 100 years **in 1763
Military Medicine
particular type of medicine based on anatomy & surgery b/c it was mostly about sewing up military wounds
Doctors referred to as…
sawbones
Inhalation Anesthesia
not invented until 1840s
- didn’t become widely used in 1850s
Antisepsis
keeping surgical conditions clean/sterile
- not introduced until 1880s
- followed germ theory by **louis pasteur (860s) **
Joseph Lister
British Surgeon
- one of the first to introduce antisepsis into his surgery
- found 1/2 of his surviving patients died of post-operative infections
**- ** read Pasteur’s work on Germ Theory & started sterilizing instruments with carbolic acid to kill germs
- decreased post-operative death to 15%
Medical treatments used by 19th century doctors
still based on Galens idea but influenced by years of military medicine
Military medicine pushed Galen’s model to the extreme & developed ?
Heroic Therapy
**Galens model - **balance
**Military Mind - **if a little was good, alot was better
Heroic Therapy
based on principle of huge intervention
blood-letting
blistering
purging
vomiting
tonics
Blood-letting
- based on theory that if you let some blood out of body that it would heal person
- cut veins or used leeches
Blistering
believed to remove/suck poison from body
Purging
clearing bowels by giving patient a diarrhetic (causes diarrhea) - calomel & mercurous chloride
Vomiting
induced by giving an emetic - tartar (tartar ate of antinomy)
Tonics
made from compounds of arsenic or opium
Licensing system - late 18th & 19th Century
Canadian government tried to introduce new legislation to restrict medical practice to only physicians
→ licensing system: only licensed physicians allowed to practice medicine
First Medical School in Canada
was established in 1824 in Montreal
Monopolies in Canada
Fur Trade → Royal Charter gave monopoly to Hudson Bay Company → monopoly on fur trade given by king of England
Why did Canadian State support Doctors so strongly?
it is believed that it is because doctors are good for peoples health
but the real reason is because they were always a tight-knit elite group so because of their high social position they were given monopoly
Characteristics of Doctors in 18th Century
only male
all went to medical school (wealthy bc they could afford it)
- family/social ties to political/economic leaders of Canada or wealthy/influential people in Britian
- mostly military doctors
Military were respected & had high prestige because?
Canada has started with century of warfare
course of medicine was determined by?
by power struggle between different groups trying to establish themselves as healthcare providers
1830s
- (2) new brands of medicine came to Canada from?
1) USA
2) Germany
1) USA
ecclecticism/herbalism
founded by Samuel Thomson
- New England Farmer rediscovered techniques of women’s traditional herbal med.
- argued that conventional med = disaster & techniques of orthodox med. = “instruments of death”
advocated for herbal meds, steam baths & bed rest
2) Germany
**homeopathy: **German Doc- Samuel Hahnemann - rejected heroic therapy
- like cures like
also rediscovered herbal medicine
- argued drugs should be given in microscopic doses (anything harmful in large doses would promote good health in small microscopic doses) - however he did not use inoculation, used herbal medicine (Echinacea)
Similarities between Samuel Thomson & Samuel Hahnmann
both rejected Heroic therapy
- emphasized bed rest
rediscovered herbal meds
both aided in popularity increase of eclecticism & homeopathy that pressured gov. to license them in 1860s
1869
conventional doctors formed General Medical Council
**- **eclectics & homeopaths invited to join → over 200 licensed to practice but they had to go to medical school first
eclectics agreed → became absorbed into regular med. & ceased to exist
homeopaths rejected - quit council & continued to practice
how did Confederation change Homeopathy?
modern Canada was born
- *federal** government introduced
- better able to enforce licensing system
- homeopaths driven underground in late 19th century
Resurgence of homeopathy in the…
early 20th century
Another group of men challenged Canadian physicians for control of HC
→ American Doctors
How was the USA different from Canada with respect to medical practice?
no old boys network
no pressure on gov to provide monopoly
- turned to private sector
- private med. schools tuition = relatively cheap entry virtually unrestricted
had far more docs
Why did American Doctors look to Canada for a place to practice?
less competition
- USA had more doctors
How did the Canadian doctors deal with US doctors coming to Canada?
public campaign → against influx of American Doctors (called yankee loafers)
late 19th century → law passed that only docs with Canadian degrees could practice
late 1880s → every province had this legislation
length of medical school in
a) USA
b) Canada
a) 2 years
b) 5 years
3rd World Countries → how did they challenge that you needed years of medical school
developed 6 month courses → to train paramedics could handle 70-80% of what doctors can
1980s/90s → recession
pressure to develop cheaper HC
→ nurse practitioners by 2010
→ just over 1,600 nurse practitioners in Canada
1910 - Flexner Report
responsible for creation of modern scientific medicine
- “the document that helped change modern medicine from quackery to responsible practice”
Abraham Flexner
schoolmaster
→ commissioned by Carnegie foundation of NY to conduct study on medical education
**Abraham Flexner **→ concluded that?
medical education = absolute disaster,
all medical schools should be shut down immediately
How many universities did Flexner give seal of approval to?
5 - Harvard, Mcgill, U of Toronto & 2 others in USA
What were Flexners recommendations? (3)
- shut down majority of medical schools
- rather than private medical schools, medicine should be taught exclusively at universities at graduate level by full-time qualified faculty
- should have access to lab, research & hospital facilities (to connect medical education to medical practice)
Flexner managed to persuade both US & Canadian governments as well as the Carnegie & Rockafeller families to put a lot of money into reforming medical schools. What made his argument so persuasive?
the coming of WW1 (1914-1919) which introduced conscription
Explain how the coming of WW1 made Flexners argument so persuasive
many men who were conscripted failed medical exam meaning they were unfit for military service which forced gov. to change attitude & finally recognize HC was inadequate - beginning with medical education
The Flexner Report changed (2) major things
1) structure of medical education
2) medicine in general
How did the Flexner Report impact the USA?
- med schools either shut down or affiliated with universities
- outlawed other forms of medicine
- stricter regulations for medical care
How did the Flexner Report impact Canada?
had less impact on the structure but larger impact on CONTENT
- standards improved (research, HC, education)
What is the time period that genuinely scientific/effective healthcare began in North America?
1910s & 20s
When did the chance of patients being helped by doctors rise above 50%?
after Flexner Report
in particular, huge change from integration of practical HC with universities which led to research
Pharmaceuticals → CHEMOTHERAPY REVOLUTION
1920s
→ 1st time effective chemical drugs were invented - variety of antibiotics developed that greatly improved health standards,
especially after becoming widely available in late 1940s/50s
Importance of
a) Alexander Fleming
b) Bantings & Best
a) discovered penicillin
b) discovered insulin in 1922
Chemotherapy Revolution lead to introduction of?
series of MIRACLE DRUGS
Miracle Drugs
drugs that could cure so-called incurable diseases
Miracle Drugs helped improve the public’s view of doctors in what way?
led public to genuinely respect & want to go to doctors
- increased demand for doctors
How did rural areas concerns change after the Chemotherapy Revolution?
rural areas were concerned about the absence of doctors in their areas
difference between the 19th & 20th Century in the publics demand for doctors
19th → gov tried to force people to go
20th → public demanded more access to doctors
What was the governments response to the public demand for doctors?
Medicare
Which province led the way for Canada in respect to Medicare?
Saskatchewan
How did SK lead the way for Canada (with medicare)?
SK is the most agricultural province
What dramatic change in HC was pioneered by SK?
change from individual-based system to a system based on gov. paying doctors for medical treatments
What (2) things resulting from SK being the most agricultural province contributed to the introduction of MEDICARE?
1) full of small rural communities where few doctors wanted to live/work
2) province of farming communities
Explain how SK being a province:
1) full of small rural communities where few doctors wanted to live/work… contributed to creation of medicare
most of SK served by horse & buggy doctors so they only visited each town every few weeks/months
- the ill had to wait or travel
Explain how SK being a
2) province of farming communities … contributed to creation of medicare
traditional farming community spirit of Mutual Aid
- neighbours helping each other (collectivity)
- when they felt they needed to attract more docs, introduced MUNICIPAL DOCTOR PLAN
MUNICIPAL DOCTOR PLAN
allowed towns/municipalities to pay doctor annual fee to provide medical services (benefited doctors b/c they had guaranteed income)
Explain the problem of default rates?
doctors fees raised but many people were too poor to pay
- rise in default rates was a problem in the 20s
- even worse in the 30s because of US stock market crash (great depression)
How was the problem of default rates solved by intro of medicare?
guaranteed income for doctors in troubled time - paid collectively through taxes through municipality
Now in historical context, what can be seen as the first step in the Healthcare Revolution?
Municipal Doctor Plan
Sarnia - 1914
pilot project of Municipal Doctor Plan
the Municipal Doctor Plan was backed up by?
passing of Rural Municipality Act in 1916
Rural Municipality Act in 1916
- allowed all SK townships for 1st time to levy tax on citizens specifically to set up fund to pay for doctor
1917 - Union Hospital Act
expanded idea because it allowed several townships to combine into health districts so together they could afford to maintain hospital
Hospitals were built partly for the purpose of?
attracting doctors
Once these acts were passed…
Municipal Doctor Plan spread across SK & continued until late 40s after WWII
(by this time ~200 SK towns used MDP & also spread to neighbouring towns of MB & AB)
How did the change from municipal to provincial government occur for funding of HC?
MDP spread swiftly across SK & neighbouring provinces (smaller scale)
- more demands that funding & organization of HC should be funded by provincial level
- demanded intro of PUBLIC HEALTH INSURANCE
What was the obstacle to public health insurance?
none of the leading politicians wanted it b/c they declared it was “socialized medicine” & it was a stepping stone to turning Canada into socialist & then communist country
How did SK overcome politicians who did not want public health insurance?
established new political party → Co-operative Commonwealth Federation (CCF)
Co-operative Commonwealth Federation (CCF)
left wing party
- demanded major changes in gov. policy most of which involved intro of welfare state
the CCF argued that…
Canadian government should take responsibility for well-being of Canadians through introduction of measures such as unemployment insurance**, higher **pensions**, **social security** & **universal government funded HC
1944
CCF won provincial election & formed provincial government under leadership of Tommy Douglas (introduced medicare to Canada)
CCF popularity
grew slowly at first in the 30s but more quickly in late 30s/early 40s
When did the CCF win the provincial election?
in 1944 under leadership of Tommy Douglas
Tommy Douglas
premier of SK from 1944-1961 deserves title of Father of Modern Medicare - universal medical care was his #1 priority
What led Tommy Douglas to his life-time commitment for providing universal healthcare?
as a child, suffered from osteomyelitis - disease of the bone
- couldnt afford series of operations needed to save his leg
- one orthopedic surgeon said he would perform operations for free if he could use it for experience for other medical students
- made TD realize many other Canadians may not be this lucky
1945
CCF introduced free medical care for the poorest people (pensioners & unemployed)
- free mental health care
- free polio treatment
1946
CCF introduced first district-wide medical insurance program
- pilot program in Swift Current
1947
Introduced the Hospital Insurance Plan
- intended to provide gov-paid hospital care to everyone in SK
- by end of 1947: already guaranteed of 90% of SK had access to state-funded hospital services
Throughout 1950s, what made TD the most popular premier in SK?
these HC measures & other welfare state measures
The growing popularity of the CCF & their principles of HC pressured federal politicians to..
take these HC measures & expand them to the federal level
Who was in power (federal) by the end of WWII?
Liberals under Mackenzie King
What did the Liberals introduce for the 1st time that raised their popularity?
introduced welfare state policy at federal level
(the established pairing of Tories & Liberals was under threat)
1948
Federal Gov. began program in giving hospital construction grants to provinces
The 1950s saw the… than any other comparable period
fastest growth in hospital construction
What became the centerpieces of modern HC?
hospitals
1958
Fed. Gov. passed Hospital Insurance & Diagnostic Services Act
Hospital Insurance & Diagnostic Services Act - 1958
modelled on SK Hospital Insurance Plan
- made hospital services freely available nation-wide
What led to the creation of the Hospital Insurance & Diagnostic Services Act in 1958?
the success of SK hospital plan & resultant public pressure to expand
1959
TD announced CCF would be introducing Prepaid Medical Care (Medicare)
the purpose of Prepaid Medical Care (Medicare)
to expand government funding from just paying for hospitals to all authorized medical services
effectively cutting all financial ties between doctor & patient
Although the public was keen on the idea of Medicare, doctors were not. Why?
they were not able to raise their fees b/c they were taken out of free market & gov became their only client
Medicare put the government in the position of ____ which would allow them to?
monopsonist - one who is a single buyer for product/ service of many sellers this would allow them to lower fees
**1960 - **Provincial Election was all about?
those against and those for Medicare practically a referendum on HC
What stance did the SK Medical Association have?
backed up by all right wing conservatives
mounted visious propaganda campaign against Tommy Douglas
- called TD a **communist, fascist **
Despite the SK Med Association’s attempts against Medicare…
Tommy Douglas was still reelected
1961
introduced SK Medical Insurance Act which put medicare into practice in SK
Tommy Douglas’s last act as premier
the SK MEDICAL INSURANCE ACT
in 1961, TD resigned as premier and the CCF..
formed alliance with Trade Unions of the Canadian Labor Congress (umbrella organization of unions) - - - CCF became the **NDP **
In 1962, when Medicare was introduced…
most SK doctors went on strike & suspended everything but emergency services (1st doc strike in Canada)
CCF stood firm & after 3 weeks, strike ended & doctors reached a sort of compromise with the government
SK government gave doctors the option to opt-out & still bill individually. However this option died out because…
public would rather government pay for HC services
by ___ over ___% of doctors were sending their bills directly to insurance commission
**1967 → **95%
by 1967, over 95% of SK doctors were sending their bills directly to insurance commission, which means that..
SK established Medicare in the course of the 60s and was the 1st province to do so
CCF became the?
NDP
At the federal level, the NDP continued to press for?
overhaul of Canada’s HC system
After continued pressure from NDP to change our HC system…
the Federal gov. established a Royal Commision to look into it (**Hall Report) **
1964 - Hall Report looked at?
both public & private health insurance in Canada
The Hall Report (1964) revealed that..?
private health insurance had existed for over 25 years
** **but only 50% of Canadians were covered & much of that coverage was inadequate
After the findings outlined in the Hall Report, What did the federal government do?
Lester B. Pearson (Liberal PM) announced his gov. would introduce cost-sharing scheme
cost-sharing scheme
federal gov paid 1/2 of prov. medical care program if they met the criteria of universal access
1966
Medical Care Act - cost-sharing to provinces & brought Medicare to Canada as a whole
Which provinces initially qualified for this cost-sharing proposal?
SK & BC all other prov. govs were right wing & opposed
How did all the other provinces agree to Medicare?
SK & BC started recieving millions of dollars & other provinces wanted to get in on this
by the end of 1970..
every province had introduced a universal medical insurance plan
Although initially most doctors opposed Medicare, it gained their support for (2) reasons
1) doctors realized they couldnt win
2) quickly learned that their fear of gov. lowering their fees was unfounded
Despite doctors worries of their fees being lowered, throughout the late 60s/early 70s…
doctors fees increased
by mid-1970s, doctors average income was how many times the national average income?
5.5x
between 1968 & 1978, the # of doctors increased by..
50% which is the largest single decade expansion in Canadian history
Greatest expansion of government spending on HC
late 60s/early 70s
The public supported the increase in gov. spending in HC as long as…
economy was in a boom period & there was plenty of $ to pay for HC
However, the public’s view on increased HC spending changed in 1973 because?
Arabs countries formed OPEC (Organization of Petroleum Exporting Countries)
- nearly quadrupled price of oil which increased cost of everything
- profits fell & more businesses were going bankrupt
This period of low wealth in Canada is known as?
the Great Recession - late 70s
Age of Cutbacks
(70s) following the Great Recession
- new laws introduced to cut back on costs
What act was established in 1977?
Established Programs Financing Act
1977 - Established Programs Financing Act
changed basic principle of Medicare from cost-sharing to block funding
- lump sum barely 1/2 of what federal funding had been the previous year, meaning provinces had to pay 3/4
Since the change to block funding (global budgeting) Medicare has grown to be the …
largest single item on provincial budgets
as of 2011, ___% of all provincial budgets was for Medicare
42%
In order for provinces to pay for Medicare, the 1977 act also allowed them to..
raise taxes & introduce user fees on non-essential HC services (private room, tv/phone)
Controversial method used by provinces to cut costs
doctors accepted lower fees & in exchange they were given the ability to extra-bill patients directly
Extra-billing by 1980
Ontario & Alberta - over 1/3 of patients being extra billed Federal gov put a stop to this
in 1984
Canada Health Act
Canada Health Act- 1984
still the primary legal basis for HC in Canada
- eliminated extra-billing indirectly
- decided it was contrary to principles of Medicare
how did the Canada Health Act indirectly eliminate extra-billing?
every dollar province saved from extra-billing would be lost from federal funding
What was the problem with eliminating extra-billing?
doctors unhappy
When Ontario implemented act at start of 1986…
led to 2nd doctors strike in Canadian history but quickly ended after only 3 weeks
Who was in power during the 2nd doctors strike in 1986?
Conservaties under power of Brian Mulroney
With the doctors defeated, the conservative gov. quickly moved to restrict…
growth in HC spending
The conservative gov. restricted federal spending on HC in __, ___ and in ____ …
1986, 1989, and in 1990 - straight freeze on HC spending for foreseeable future
While the Conservativeswere in office from1984 to 1992, they cut ___ ___ dollars from HC budget
30 billion
as a result of this 30 billion $$ budget cut…
beds, wards & even hospitals shut down
between 1986-1995…
of public hospitals fell by 15% # of hospital beds fell by 11%
1993 - Political Party in Power
Liberals took over under Jean Chretien
How did the Liberals change things in 1993?
found new way to introduce more cutbacks to HC & social programs in general
1995 - changes to Transfer payments
Liberals put together Federal Transfer Payments for health, education & welfare into lump sum - Canada Health & Social Transfer (CHST)
(2) advantaged of the CHST for the Fed. Gov.
1) cut total amount of $ going to provinces
2) deflected public attention to provinces
How long did the CHST last?
Until 2003
Since 2003, HC funding from Federal Government comes from?
Canada Health Transfer (CHT)
between 1995 & 2003
cutbacks led to more closures of bed, wards & hospitals (Plains hospital in Regina closed in 1988)
Also introduced other problems for HC system
staff shortages
de-insuring of med. services
lengthening of waiting lists across Canada
most serious problem with the cutbacks introduced
hospitals turned away patients
- even emergency patients
- ambulances shuttled form hospital to hospital to find somewhere for patient
- people died in ambulance
1999 - consequences of cutbacks
patients died due to lack of beds/wards/hospitals in North Battleford, Yorkton & Prince Albert
The cutbacks and resultant deaths led to?
This situation led to mounting public outrage/outcry
When economy finally improved in __/___ __ …
mid/late 90s → provincial politicians began to demand more money from ottawa
Premier’s Summits - all premiers agreed to…
demand more $$ for social programs in general & HC in particular
1997
Turning point - under pressure from politicians federal gov. finally agreed to put more $$ into HC - 1.5 billion dollars
1999 & 2000 - Funding for HC
further increases in federal funding announced
By the time the CHST was broken up in 2003, how much had HC spending reached?
almost 20 billion dollars
2003 - GDP spent on HC
9.46% of GDP was spent on HC
in 2003, 9.46% of GDP was allocated to HC … how does this compare to 1992?
less than in 1992 - which was before liberal cutbacks but after conservative cutbacks
2003 also saw report delivered by …
Royal Commission - headed by former SK premier - Roy Romanow
Romanow Commission concluded that?
concluded that HC in Canada still needed major infusion of $$
2004 - HC funding
Premiers help special HC conference which demanded an increase in HC funding from fed. gov.
As a result of the 2004 special HC conference…
Fed. Gov. committed 41.3$ billion dollars for HC over next 10 years
2006 - Political Party in Power
Stephen Harper & Conservatives elected - only had minority
2011 - Political Party in Power
Harper obtained majority gov.
One of the first things Harper did once he obtained a majority government was…
cut 36 billion from Canada Health Transfer to save money (real motive is believed to be because he wanted to open up possibility of private HC companies)
Harper’s cutbacks put a lot of pressure on ___ & ___ __
politicians & HC workers
doctors & nurses told to do more with less
- expected to treat more patients in less time with
resources
Inevitable result of this pressure on doctors
rise in physical & mental exhaustion which adversely affect their health & job performance (& indirectly affects the health of the public)
Occupation in crisis
Nurses
Impact of cutbacks on Doctors vs. Nurses
doctors have always been a relatively privileged group
- still had to work harder (reported increased stress) but incomes have remained high
Nurses have received the most pressure yet earn the same as national avg income
in 2012, average annual income of:
a) GPs
b) specialists
a) 180k
b) 350k
History of nursing begins with?
Florence Nightingale
Florence Nightingale - background before Crimean war
born into relatively wealthy family in 1820 - strong-willed woman - despite her familys strong objections to working as a nurse, she studied HC anyways - became director of nursing home in England where she transformed it into an efficient little hospital
Nightingale effectively transformed nursing from… into…?
FROM occupation restricted to untrained nuns/charity workers INTO genuine occupation requiring vocational education
Nightingale is famous for her work in? (years?)
the Crimean War (1853-1856)
What was the nickname Nightingale earned in the Crimean war? For what reason?
Lady with the Lamp - for her nightly rounds of checkin on patients with her lamp
When Nightingale and her group of nurses first arrived in Crimea, how were they recieved?
met with hostility from doctors there (doctors were obsessed about maintaining control/a monopoly over HC)
How did Nightingale respond to the doctors hostility? (3 pts)
reassured them that nurses were not competition and were strictly there to obey the doctors orders & do women’s work (cooking & cleaning)
How did Nightingale make a difference by cooking & cleaning in the Crimean War (1853-1856)?
by taking over cooking & cleaning, she was able to introduce proper standards of nutrition & sanitation which was previously ignored by male doctors - mortality rates declined sharply
One famous case where Nightingale helped improve sanitation
persuaded military officers to go upstream & found dead horse spewing bacteria - convinced them to move it
Florence Nightingale -After Crimean War
took heavy toll on her, was ill & bed-ridden most of her life - became public heroine & used her fame to write about nursing, engage in political activism & organizational work that laid the foundation for modern nurse training
Nursing - occupation for women
virtually only paid occupation for women - therefore it was very attractive for those who wanted an education & career (middle-class womeN)
First Nursing School in Canada
St.Catharines - established in 1874 in Ontario - based on Nightingales model of nursing
of nursing schools in Canada in… a) 1900 b) by 1909 c) by 1930
a) 20 b) 170 c) 220
The first 30 years of the 20th Century were known as the period that..
saw the greatest expansion in nursing
Impact of the Flexner Report on Nursing
following the recommendations of the Flexner report, the **first university degree program in nursing was established in 1919 at UBC **
1900s: # of nurses vs doctors
200 nurses compared to 5,000 doctors
1930: # of nurses vs doctors
30,000 nurses compared to 10,000
After 1930, what happened to the rate of growth of nursing?
declined
Despite the decline in the rate of growth of nursing after 1930, Throughout the 20th Century…
nursing maintained average annual increase of 50% - compared to less than 10% for doctors
By 2006, How many registered nurses in Canada? What % were women?
320,000 94% women
Nurses made up __ of all HC providers becoming the…
2/3 single largest profession in Canada
In economic terms, the expansion of nursing allowed…
Canadian women to get back into the labor market from which they had been virtually squeezed out of by late 19th century
Routes for Economic Independance for women in early 20th century? (2)
1) Inheritance 2) nursing
Despite being the only route to independance (apart from inheritance) for women, there were still drawbacks/limitations..
hard road to travel only gave limited form of independance
Although Nightingale herself was strong & independent, her teaching methods demanded…
strict obediance to male doctors
Argument about Nightingale’s teaching methods
some say she did a disservice to women but may have been the only way to be accepted & overcome the hostility of male doctors
Only way that nursing could be accepted by doctors was if…
they defined themselves as an AUXILLARY OCCUPATION to that of doctors (a supplementary occupation)
The general attitude about nursing by male doctors
women were still doing women’s work, just in a hospital setting - which was acceptable to male docs at the time
Connection b/w Patriarchal relations that existed in Victorian family/society & HC
the patriarchal relations that existed in Victorian society/family (era: 1837-1901) were reproduced within the hospital
The Patriarchal (male-dominated gender) relations that existed in Victorian society/family were reproduced within hospital, creating…
a new gender division of labor in HC
Men providing cuts & chemicals (surgery & drugs) & women providing nutrition & sanitation was a reasonable division of labor. However, the problem was..
men ended up taking most of the money & power but the women did most of the work - particularly nursing students
Early 20th Century - nursing students
- treated like slave laborers - work consisted of hard manual labor (washing floors/windows, changing beds, cooking) - forced to work 12-16 hours/day in hospital WITHOUT pay - only received training, room and board
When did Nursing students get paid? How much compared to average male wage?
Only after they had graduated & recieved their Nursing Diploma - only 1/2 of average male wage
Nursing students training consisted of..
mostly on-the-job training which consisted of working hard while being supervised by small permanent staff of grad nurses - no time for actual study/theory
How long to finish a Nursing Degree in the early 20th century?
2-3 years
How did the hospitals benefit from nursing students in the late early 20th century?
provided hospitals with rotating pool of cheap labor
After graduation, where would nurses work?
some worked as private nurses but increasings #s found jobs in hospitals
The explosive growth of nursing schools was greatly motivated by?
the desire of hospital administrators & doctors to have cheap labor
What effect did permanent nursing staff have on hospitals?
no more cheap labor - less motivation for growth of nursing profession
How did nursing change hospitals in early 20th Century compared to 19th century?
19th century - hospitals were places people only went to die 20th - changed hospitals into hygienic centers of care & recovery which changed public image of hospitals
Nursing made major contribution to…
medical profession & doctors reputation yet still they were heavily exploited - paid virtually nothing for a lot of work
As the # of nurses rose, they begin to..
fight for their rights
Nurses realized the only way to get better wages & working conditions was through (2)?
self-organization & collective action
1908
Canadians Nurses established Canadian National Association of Trained Nurses (CNATN)
1924
reorganization CNATN and renamed as Canadian Nurses Assocation
Canadian Nurses Association
still remains main organization that represents nurses interests today
First goal of CNATN in 1908
establish provincial registries of qualified nurses -only these nurses could practice nursing
1910
began to set up registries & nurses became known as RNs
Through the process of registering nurses.. the nursing profession tried to…
gain monopoly on role of assistant caregiver but never been as successful as doctors in achieving a monopoly
By WW2 (1939-1945) ..Nurses
organized enough to gain some concessions - gained 8 hour day
1950 - nurses income
nurses pay was 60% of avg national income
by 1980 - nurses income
risen to avg national income - mostly due to pressure from nurses
In addition to pushing for better wages & working conditions, Nurses also demanded?
real education and not just on-the-job training
1964 - Nursing
Hall report - Royal commission looking into HC delivered report that was critical of nursing education in Canada
The Hall Report of 1964 recommended what change to nursing?
seperation of nursing training from hospital demands for nursing services (nursing education should be seperate from training)
How did the government respond to the Royal Commission’s recommendations of seperating nursing education from training?
in late 60s/early 70s → nursing education moved away from hospital schools into newly created diploma programs in universities
Nursing ___ & ___ significantly improved after the government responded to the Royal Commissions recommendations.
skills & standards
What other change did the government make other than to nursing education?
changed immigration policy to attract more nurses
As a result of he change in Canadian immigration policy…
over 20,000 nurses immigrated to Canada - mostly from Britain
Britain’s NHS
Britain’s National Health Service/System (NHS) was more advanced & developed than Canada’s HC system
NHS - impact on Canadian HC
Canadian government deliberately tried to upgrade nursing standards & increase # of nurses
The government’s attempts to upgrade nursing standards & increase # of nurses by changing immigration laws was part of..
overall policy of Canada to establish Medicare by copying Britain’s NHS
Time period that saw considerable expansion in # of nurses
1960s & 1870s
The expansion in the # of nurses in 60s & 70s was accompanied by..
a growing division of labor
Nursing saw an increase in (3) things
1) specialization 2) fragmentation 3) hierarchization
Nursing began to generate its own __ ___
auxilliary occupations (therapists, dieticians, orderlies, technicians)
specialization of nursing
some nurses took more education to upgrade their qualifications & specialize in one area of nursing - realized pay only increased marginally (still 3/4 of nurses are general duty nurses)
While there were some changes in nursing, more changes changes occured where?
at bottom of occupational ladder- auxiliary occupations
How did hospital administrator try to cut nurses wage bill after they had just gotten their wages increased?
replaced many nurses with registered nursing assistants (1970s) - when RNAs got organized & pushed for higher wages, they were replaced with nursing attendants (1980s)
The replacement of nurses with registered nursing assistants & then nursings attendants demonstrates…
class struggle in action which is seen in any area of the economy - cycle that is built into capitalism
Despite all these changes to the Nursing field, what remained constant? How?
Ongoing feminization of HC system - by 1990s, 2/3 of HC system workers were nurses (90% women) nearly 80% of all HC workers = women
Despite the increasing proportion of women in the HC system..
women’s influence & power has not grown in proportion to their #s
in the late 80s/90s, how were hospital bills broken down?
into thirds 1/3 for doctors 1/3 for nurses 1/3 for administrative & support staff
Nursing expanded greatly in 60s & 70s, but in 80s & 90s, there was a major increase in..
administrative staff
(2) reasons for the major increase in administrative staff in hospitals
1) certain support services were removed from nursing & subcontracted to private companies 2) growth & change in kind of hospital administrators
80s → certain support services removed from nursing
hotel services (cooking, cleaning, laundry, catering) were no longer nurses responsibility & hospitals subcontracted these to private companies
What was the beginning of privatization of HC
subcontracting private companies for hotel services
Growth & change in in kind of hospital administrators
in 5 years (1981-86), # of HC administrators grew by over 2/3s - hospitals began to hire administrators outside of HC field - mostly managers from private sector who had an education in management & not HC
Before the 80s, who were hospital administrators?
mostly doctors or other HC workers that had climbed administrative ladder internally
by 1993.. HC administrators characteristics
1/3 of HC administrators had NO HC experience - mostly men - business degree/experience in management
Changes in control/influence due to the new kind of hospital administrators
doctors lost control of hospitals - womens influence decline
How did these new hospital administrators view their job & how did this affect working in the hospital?
saw their job as the same kind they had in private sector - pressure workers work as hard as possible
Why did most of pressure from hospital administrators fall on nurses?
doctors were still seen as relatively privileged group, middle-class professionals who deserved to not be pushed as hard
Managerial structure emerged in hospitals
private administrators > doctors > nurses & auxiliaries
To the hospital administrators, nurses were seen as..
the working class of the HC system which management has always pushed to work harder
How did Hospital administrators push nurses to work harder??
through the process of deskilling
deskilling
breaking down jobs into simple tasks so highly paid experts can be replaced with less-skilled cheaper workers
(2) advantages of deskilling for management
1) increased control over workforce 2) saves $$ by decreased wage bill
Deskilling - first noted in academic terms by..
Chares Babbaged in early 19th Century →known as Babbage Principle
Other terms for deskilling
late 19th century → Fordism (Henry Ford) early 20th→ Taylorism (named after Frederick Taylor who invented time & motion studies & scientific management) late 20th→ Mcdonaldization
Terms for Deskilling within the field of HC
Managerial Ideology Case-mix grouping Total Quality Management
Why should TQM be called Totalitarian Quality Management?
because it introduces total control over nurses work
What were nurses told that TQM do?
- provide greater autonomy - make jobs easier by improving job efficiency - hep assess staffing needs
What did TQM actually do?
breaks down nursing into specific jobs & assigning specific amounts of time for each task (based on polls asking nurses how much time they needed for each) - allowed administration to cut amount of time allowed for each job to force nurses to work harder/faster & save money by not hiring more nurses
Negative consequences of TQM
TQM was taken from factory work where assembly lines can be standardized to improve efficiency - However, people are not machines & HC cannot be standarized because it wouldnt account for personal differences
How does the standardization of HC by TQM affect nursing care how?
left nurses without enough time so that they were constantly falling behind on tasks - made decision making difficult b/c they had less time to make possibly life-or-death choices
Quality of Care given by nurses after TQM introduced
of mistakes increased # of people harmed increased because they did not have enough time
TQM’s attempt to standardize HC ad negative effects on…
the patients & the nurses
Study by Canadian Institute for Health Information (2004) - main finding
over 5 million CDNs reported they or member of their family had been harmed by medical errors in hospital
Study by Canadian Institute for Health Information (2004) statistics given (5)
- 1 in 9 reported receiving incorrect medication/dosage - 1/9 adults & 1/11 children contracted infection - 1/81 newborns suffered birth trauma - 1/~1000 seniors suffer hip fracture - 1/~7000 reported having foreign object left inside them after procedure
TQM treats nurses as if they were?
interchangeable components on assembly line
How has TQM resulted in a lack of continuity of HC?
different nurses do different jobs on same patient → unable to learn patients overall health situation so nurses can’t treat patients like individual with individual needs
TQM is the ultimate extension of? & denial of?
extension of male mechanical model & denial of traditional holistic female approach to HC
TQM turned the continuous process of care into?
series of compartmentalized cures that were about seeing to a patients minimum needs
TQM also eliminated..
subjective side of HC - part of nurses work called emotional labor
Explain how private sector administrators view HC & how that is reflected in their management.
administrators deal with balance sheets, numbers & money - the comfort that nurses provided is invisible & seen as a waste of time that must be eliminated to increase speed, efficiency & decrease cost
How does TQM treat a) nurses b) patients
a) as if they were uneducated unskilled labourers who have to be told what/how/when to do things b) treats patients in a standardized manner
In Sociological Terms, professionals want control over their own __ __
labor process
TQM has greatly increased level of ___ that nurses experience from their jobs
alienation
How has TQM affected quality of care given by nurses? How has this affected hospital in last 30 years?
has forced them to do their jobs badly bc they do not have enough time or resources - health sanitation & nutrition levels declined over last 30 years
In general, how has TQM affected nurses?
- decrease in quality of care (more mistakes etc) - behind in work - decreased morale - blame themselves - increased physical & mental stress - rise in work-related injuries & illness
By the late 1990s, as a result of TQM, nursing has become known as..
the sickest profession in Canada
Nursing - Sickest Profession in Canada - Example
1997 - sick leave avg CDN = 1 week nurses = weeks
Nurse Burnout
in 1990s, as a result of TQM - many nurses quit because they couldn’t take the pressure
Why is the phenomenon known as Nurse Burnout only happening in the later 20th Century?
in the late 19th/early 20th Century, nursing was really the only acceptable & paid job for women
2000 - Canadian Nurses Association study found..
~ 1/3 nurse graduates left canadian nursing within 5 years of graduating - 20% quit altogether - 10% went to USA to work in private sector (paid more)
What decade saw a sharp decline in the # of applicants & graduates of nursing schools?
1990s
Nurses graduated in Canada in 1999 vs. 2000
1999 - ~9000 2000- <5000
How did Nurses try to fight back against the increasing stress put on them? (3)
in late 1980s, Nurses Union proclaimed TQM was endangering patients life through pressure putting on nurses Provincial Nurses Unions took a stand on SAFETY TO PRACTICE issues - went on strike
First Wave of Nursing Strike
bc they were being completely ignored, wave of nursing strikes swept across Canada in late 80s/early 90s
late 80s/early 90s Nursing Strikes
1988- SK & BC 1989 - BC & Quebec 1991 - Manitoba (longest strike)
What was the result of the Nursing strikes?
a professional responsibility clause was added to nurses contracts that established channels for nurses to express their grievances
Second wave of nursing strikes - when?
late 90s/early 2000s 1999- SK
How did SK government respond to SK nurses going on strike
NDP gov met nurses w/ great hostility despite being party of the working class - ready to enact back to work legislation - used courts to threaten unions with fines & leaders with prison time
Throughout the 2000s, nurses have been ___, ___ & ____
overstressed over-supervises over-worked
2003 Statistics - Nurses Overtime
CDN nurses worked over a quarter million overtime hours in a week - equivalent to work of 7,000 full-time jobs a year
2005 - Study on Ontario Nurses - findings
58% of nurses & 66% of junior nurses experiencing symptoms of nurse burnout 1 in 3 nurses under 30 plan to quit 1 in 3 over 50 plan to retire early
2005 Study on Ontario Nurses - Symptoms of nurse-burnout - reasons for symptoms of nurse-burnout? (3)
- depression, emotional/physical exhaustion, physical illness & growing cynicism of job 1) work overload 2) lack of fairness in workplace 3) lack of empowerment (increasing supervision & not in control)
How does TQM put more pressure on nurses to quit?
their job involves making life-or-death decisions - mistakes increasing because of lack of resources/time/people - worries nurses b/c patient life & health is compromised
How has SK addressed this issue of nurse burnout?
In 2012, Premier Brad Wall announced that SK will once again lead way for Canada in improving HC (just like TD did) → 1st province to introduce LEAN Management
LEAN Management in SK
in 2012, SK government signed 4 year contract with Seattle-based company John Black & Associates - pay 40 million over 4 years to teach LEAN management techniques in over 1,000 HC facilities
Origin of LEAN
Japan
Sensei (meaning)
one who has gone this way before voice of experience teacher
How did the public view LEAN?
initially well until 2014 - was criticized for 40 million $ price rage - Cam Broten of NDP called lean a “cult”
How has SK Premier defended Lean & its 40 million dollar cost?
says that LEAN management has already more than paid for itself - by eliminating waste & improving efficiency, has saved 35 million in blood services, 16 mill in design of new hospitals in Saskatoon & Moosejaw & million more in 100s of small savings in HC facilities all across province
How was lean created?
Toyota automobile corp. - the term was coined by American Analyst John Krafcik who wrote article about Toyota in 1988 - introduced idea of LEAN to the west
Toyota - History
founded in 1930s as small family business -has since grown to be the 5th largest corporation
The Toyota Way - History & Basis
based its production on assembly line techniques pioneered by Henry Ford In USA - concerned with efficiency & elimination of waste by standardized & simplified production process - an extension of Fordism & based on Taylorism (time & motion studies) - Flow System -production should flow smoothly - no bottle necks of unused resources - aka Just in Time system - each person finished their part of job just in time for next person to take over - dont need lots of backup inventory (save $$) -
The Toyota Way Philosphy (6) points
- managerial philosophy - established culture where everyone is committed to looking for ways to improve process - regular meetings to look for ways to do things better -emphasizes teamwork, mutual respect bw management & employees & constantly improving - decisions made by reaching consensus
How does the Toyota Way differ from standard manager-worker relationships
management regularly consults workers & gets feedback - workers are involved in the decision-making process & their opinions are respected - makes them feel like it is their company so they want to be more efficient & finds ways to do job better
What does Toyota literature say is the primary reason behind their time-saving techniques?
these time-saving techniques are by-products of the positive attitude,teamwork, mutual respect & culture of improving workforce
Why is the Toyota Way unsuccessful for many companies over the longterm?
most managers dont think & dont want to think this way - they beleive that managers should give orders & workers should obey (top-down manner) - rather than set up meetings, they hire Sensei’s to tell workers what to do which makes workers angry, decreases morale & makes workers less engaged
