Medical professionals wait ner-vously on the shore, “divided

among themselves and perceiving attackfrom without,” writes family physicianSam Shortt in The Doctor Dilemma.Imagine a Viking dragon-ship full ofberserkers from government, academiaand the public, leaping onto the strand,brandishing their war axes. What will bethe outcome of this raid? Will physicianssurvive, huddled next to the driftwoodfire of medicare, or will they be forced toembrace a foreign culture imposed bythe marauders? Shortt’s answer is that asea-change is inevitable and that assimi-lation within a new culture will be thebest outcome for physicians.

Shortt sets the scene by recountingthe amusing and preposterous attemptby a disgruntled physician to force thepremier and the minister of health ofOntario to undergo psychiatric assess-ment for their inappropriate behaviour.He then considers five key policy areas:payment of physicians, supply and dis-tribution of physicians, quality assess-ment in ambulatory care, the relation-ship between physicians and hospitalsand the role of technology. Althoughmost of these issues are familiar, thisbook is better than most accounts inboth its perspective and its thorough-ness. With his experience as a familyphysician, historian and policy analyst(he is now director of the Health PolicyResearch Unit in the Faculty of Medi-cine at Queen’s), Shortt is well placedto put these issues in context. The bookis rich with plundered treasure, con-taining over 400 references. It presentsa clear-eyed synthesis of an importantissue facing the profession, namely inte-grated care. Shortt is careful, however,

to point out that this term is often con-fused with similar ones such as man-aged care, devolution, regionalizationand comprehensive health organiza-tions, and he admits to using these in-t e r c h a n g e a b l y .

The book is well written, and Shorttis not afraid of a vivid phrase for em-phasis. There is an inevitability to eachchapter as he outlines the issues, judi-ciously considers the evidence andreaches balanced conclusions. Pub-lished evidence, where available, is putto good use, and the constraints im-posed by its lack are acknowledged.Two recurring themes are (1) that theanomaly of public payment for privatepractice has been directly responsiblefor the adversarial na-ture of physician–gov-ernment relations, and(2) that the days of pri-vate practice are num-bered and will eventu-ally be replaced bypublic payment throughsome type of integrateds y s t e m .

The Doctor Dilemmawill interest physicianswho are puzzled abouthow events seem to beovertaking them andwant to know where the profession isheading. Policy-makers anywhere inCanada who are mulling over the intro-duction of integrated health systemsshould read this book carefully. Shorttstrongly advocates a crucial role forphysicians in charting the future courseof the health care system. No doubtthere are one or two bruised bureau-crats who will beg to differ.

Many physicians will not like Shortt’scentral message that the introduction ofintegrated care will mean a shift fromfee-for-service to some other form of re-imbursement. This is likely to be a mixof sessional payments through an alter-native funding plan for specialists at aca-demic health sciences centres and amodified form of capitation for familyphysicians. Some may interpret the pro-posed policies as an attempt to controldoctors, but Shortt maintains that theyare about accountability, not control. Aclear message is that until physicianslearn to distinguish between the twothey are unlikely to reside comfortablyin the Canadian health care system.

How will the dilemma be resolved?Shortt argues that some form of inte-grated care is inevitable and will likely befor the better. He feels that the policylevers are already in place in Ontario andthat it is time for some strong politicalhands to start pushing them. As it hap-pened, Norse culture spread peacefullyand gradually through Europe and theNorth Atlantic countries over several

centuries. I ratherthink that this is how anew system, whether itbe called integratedcare or something else,will be diffused. Al-ready, the Health Ser-vices RestructuringCommission of On-tario is soliciting pilotsites for integratedhealth care systems.Physicians would bet-ter serve the profes-sion and their interests

by becoming part of this process ratherthan having integrated care imposed onthem. The Doctor Dilemma has the bestinterests of the profession at heart. It isworth reading for that fact alone.

Duncan Hunter, PhDDirector, Health Information PartnershipEastern Ontario RegionKingston, Ont.

Battling the berserkersThe doctor dilemma: public policy and the changing role of physicians under Ontario medicareS.E.D. ShorttMcGill-Queen’s University Press, Montreal & Kingston; 1999145 pp. $55 (cloth) ISBN 0-7735-1796-6$19.95 (paper) ISBN 0-7735-1794-4

The Left Atrium

6 2 JAMC • 13 JUILL. 1999; 161 (1)

© 1999 Canadian Medical Association