High Dose? Standard Dose? Doesn’t Matter! Just Get A Flu Shot!

Recently, many physicians offices have been inundated with requests for the so called “high dose” flu shot. I know I’ve had many patients ask in my own office, and this is the result of all the publicity around these shots. Pharmacies were specifically advertising that they had the high dose shots available. Heck some pharmacies even offered customers points for getting your shots. Until of course, they ran out. (Memo to pharmacies – unlike Teslas, generally not a good idea to advertise something you can’t deliver on time).

Of course once they ran out came the inevitable concerns expressed about why people couldn’t get a “high dose” shot themselves. I have also heard some isolated reports in my community about people waiting to get their flu shot until the high dose were back in supply.

But here’s the thing. There is no evidence to suggest that the high dose flu shot is actually better than the current standard dose shot. Seriously.

In 2014, a study was done looking at the high dose versus regular flu shots, particularly in older patients. The study clearly showed that there was a higher immune response in older patients with the high dose shot. But from a clinical perspective, it really only made a minor (although what statisticians will call a statistically significant) difference. 1.9% of people who got the standard flu shot went on to get the flu, and 1.4% of people who got the high dose flu shot went on to get the flu, for an effective difference of 0.5%. All this hype for 0.5%??

But more importantly, that study looked at what are called trivalent flu vaccines. In essence, both the standard and the high dose vaccines in the study were good against three strains of the flu.

However, in Ontario, our standard dose flu shot is a quadrivalent. It’s good against four strains of the flu. The high dose continues to be a trivalent. So the option for people in Ontario is to get a flu shot that has a regular dose against four strains, or a high dose shot that is good against three strains only.

Importantly, there has not been a head to head study between the high dose trivalent and the standard dose quadrivalent used in Ontario. Which means no one really knows which vaccine is better.

Heck even the Public Health Ontario Fact Sheet on flu vaccines states there is “insufficient evidence” to recommend one over the other. There is some supposition about the extra B strain that is covered in the quadrivalent vaccine not being as common in those over 65, and perhaps having a lower disease burden, but it’s not really clear cut.

So what should you do?

As I mentioned in my last blog, you should wait until November to get your flu shot. It now being November – GET IT! If you are over 65 and are unable to get the high dose, don’t sweat it, just get the standard one. Because frankly the protection you get from that is still really really good (I mean why all this fuss over a measly 0.5%??). But don’t put off getting your shot now just to wait and see if more high dose vaccines are coming.

It’s time to protect yourself and your loved ones. Both flu shots are good. Get whichever one you can, and let’s help each other stay safe.

Me getting my flu shot at the hands of my trusty nurse…..

Get Your Flu Shot…..in NOVEMBER

Every year in my office, usually just after Labour Day, the influx of phone calls begins. It’s always the same question -“When are you giving the flu shots?” While it’s easy to grumble about the increase in calls, the reality is that patients who are calling are being pro-active about their health. This is to be lauded as pro-active patients often have the best health outcomes.

Above image from St. Patricks Home of Ottawa.

This year the phone calls came earlier than ever. There’s a general sense in my practice that more people want the flu shot (a good thing) as patients are concerned about winding up in hospital, and contracting COVID19 while there. The fear of a “double threat” in hospitals is high, and I suspect that more people will get a flu shot this year because of this same fear.

This is also compounded by some erroneous information out there about what the flu is. A lot of people who have a cough, or the sniffles or a low grade fever think they have “a touch of the flu.” That’s not really the case. If you have a cold, you will have a fever, cough, and runny nose, but you will not feel like you’re on death’s doorstep.

If you have the flu, in addition to those three symptoms, you will feel like you got run over by a truck twice. The second time because the flu virus will have wanted to to ensure you really really felt it’s presence. Muscles you never knew existed will hurt for days, and it will be an experience you won’t soon forget.

So a lot of people who are getting a cold are concerned that the flu season is already starting. It’s not.

According to Canada Flu Watch, as of October 4, there is an exceptionally low level of flu activity across Canada. The percentage of positive flu tests is a mere .05%, which is well below normal. The flu is not in Canada (yet). I think most physicians would agree that an emphasis on social distancing, hand washing and mask wearing has had a large roll to play in this. Those three things don’t just reduce the spread of COVID19, they also reduce the spread of other viruses, including the flu.

Usually flu season begins around the first week of November with a few cases, peaks in January, is of concern until the end of March, and occasionally drags on into May (see below).

Graph is from the excellent Ottawa Public Health website

However, since the flu numbers are so low this year, it is likely that our flu season will be delayed somewhat. It appears that we can wait just a little bit longer to get it this year (but you should get it)!

The trick with getting the flu shot is timing. It takes your body about two weeks to build up full immunity after getting the flu shot. But, after about 28 days, the immunity starts to wane, slowly perhaps, but it does wane. (Medical nerds out there may want to read this study). Getting the flu shot too soon, means it may wear off before the season ends.

This year, what would be the best thing to do?

First, just about everybody over the age of six months should get a flu shot to protect themselves and their loved ones. The number of people who truly, truly have adverse reactions to the flu shot is very low. Talk to your doctor if you have concerns.

Second, for people who are in nursing homes and retirement homes, it probably is worthwhile getting the shot the last week of October. These patients are truly truly high risk, and it may take them longer to develop immunity.

Third, for most other people in the community, the first couple or three weeks of November are likely the ideal time to get the flu shot this year. My own office won’t even be having our flu shot clinics until November (my patients will get emailed once we firm up the logistics). This is being done to ensure that we all have a reasonable amount of immunity until the end of the flu season.

So let’s all do our part. Continue to social distance, wear a mask, wash your hands frequently (for 20 seconds) and get a flu shot in November. Together, we can ensure that the the double threat remains a threat, and not a reality.

Disclaimer: The opinion above is not individualized medical advice. It’s meant for the population as a whole. If you have specific questions or concerns, speak to your doctor.

Physician Autonomy Essential for Good Patient Care

Several years ago, one of my colleagues was having a disagreement with an external health care agency. She’s a very bright young family physician, and is extremely passionate about one part of comprehensive family medicine care. She really felt the external agency was failing in providing a reasonable level of service for one group of marginalized patients. In particular, she felt the agency’s process for accepting referrals was deeply flawed.

After months of advocacy by her, the agency finally reviewed their intake process. They then pronounced that everything was ok, because 90% of the referrals were processed accordingly.

In response, my tenacious colleague sent an email to all the family docs in the area, asking them for feedback on the referral process. She the proceeded to blast said agency for the 90% processing rate. “If a server at McDonald’s got the order wrong 10% of the time, would he still have a job?” was the line in her email that really got everyone’s attention. As a result, my colleagues sent feedback, the external agency’s response was proven inadequate, and changes were made. In her own way, my colleague was following the wisdom of Ruth Bader Ginsburg:

It also shows, in one neat example why physician autonomy is so important to patient care. Because without that autonomy, and independence, we can’t speak out. We can’t advocate for our patients even if it makes bureaucrats uncomfortable. We can’t expose those situations where patient care has been compromised.

This is, of course, exactly what those who want to take autonomy away from us want. For the most part this includes two types of people. First are health care bureaucrats, who feel that because they control the purse strings, everything should be done their way, and no pesky front line physicians should dare question their judgement or expose their flaws. The second group consists of a small number of physicians, who, while well intentioned, feel that physicians autonomy impedes whatever fancy new health program they want to implement.

Suppose you are an employee in the IT department of a corporation. You make a statement like say, “If our legal department worked at McDonald’s they would get fired because they get orders wrong 10% of the time.” What happens then? Human Resources gets involved, you get called out for making derogatory comments, the CEO might even get involved, you get disciplined and basically told to shut up. Even (especially?) if you are right in the first place.

This is exactly what those who oppose physician autonomy want.

The anti-autonomy crowd feels that physicians resist change. Therefore, the thinking goes, physicians will use their autonomy and independence to impede whatever new program/model/team is being promoted. Hence, autonomy must be curtailed so physicians can do what they are told, and accept whatever the powers that be tell them is good for them.

However, this couldn’t be further from the truth. The vast majority of physicians are open to new ways of doing things. If they truly believe a new process will help their patients, and help their lives, they will adapt. This is why we use new medications, new treatment protocols and yes, newer models of health care delivery than we used in the past. Medicine would not have changed so much in the past 25 years, if it wasn’t for the willingness of physicians to explore newer and different methods of delivering health care.

But as my friend’s example shows (and there are many like hers), what is essential to the provision of good patient care, is for physicians to retain their ability to speak out. My friend saw an area where a health care agency was failing a group of patients. Because she didn’t have to fear retribution in the form of being hauled up in front of Human Resources, she was able to effectively advocate for patients (who in this case happened to be too frail to advocate for themselves). Eventually, due to her persistence, the agency recognized their errors and fixed their flawed process.

In much the same way as we explore transforming the health system again (in Ontario these are to be done with the Ontario Health Teams or OHTs), it is fundamentally important to ensure that physician autonomy is protected in these models. This will allow physicians to speak up if the implementation plans are not going the way they should, or if programs promoted by the leaders are not really going to help patients. While painful for those in charge to hear criticisms, it results in better outcomes in the long run because the new programs will be better, stronger and more effective.

Let’s hope that as the new OHTs are developed (full disclosure, I support the concept) the message of the essential nature of physician autonomy is not lost. Physician autonomy has allowed us to be the best possible advocates for patient care in the past. If we can no longer, as Ginsburg urged, fight for the things we care about, it will be the patients who suffer.

Integrated Health Care: If Not Now, When?

As always, opinions in the following blog are mine, and not necessarily those of the Ontario Medical Association.

Recently, Canada Health Infoway, a non-profit organization funded by the federal government to develop digital health solutions, announced that their electronic prescription solution, PrescribeIT, was adopted by the Shoppers Drug Mart and Loblaw chain of pharmacies. This followed on the heels of PrescibeIT being accepted by the Rexall chain. PrescribeIT allows physicians to essentially send electronic prescriptions from their Electronic Medical Records (EMRs) to pharmacies directly, eliminating the need for paper prescriptions.

Reaction from many physician leaders was generally positive:

Other reports indicate how solutions like this have helped during the current COVID19 pandemic. In England for example, 85% of prescriptions are now electronic, thus helping with social distancing.

While I’m glad progress is (finally) being made, I’m forced to ask one question. Why did it take so bloody long?

As I’ve mentioned repeatedly to various health care bureaucrats over the years, my region (Georgian Bay) has had electronic prescriptions for ELEVEN YEARS now. We’ve regularly been emailing pharmacies and had them message us with either requests, or further information.

Our project additionally allows for pharmacists to become part of the health care team by allowing them limited access to a few important pieces of health information they need to do their job properly. For example, they are allowed access to the patients kidney function tests (knowing that many drugs are excreted by the kidney). In that way, I have gotten much advice about changing the dosage of medicine based on how someone’s kidneys are working.

Building on this project, our local area has also ensured that the our After Hours Clinic uses the local EMR, so if patients have to go there, the physician on call can easily access their charts. The local hospital allows us to house our server in their IT room (increases security because of all the firewalls). The advantage of this is that hospital physicians can access all the outpatient records if needed, and provide better care for patients. Even our local hospice has access to this so that patients can get the care they deserve during their last days.

We were even able, for a three years to have the nursing homes access and securely message our EMRs. The result was an over 50% reduction in admissions to hospital from the nursing homes. The cost of the project was $35,000 per year, but the government couldn’t find the right pocket of money to fund it (sigh – see here for how the bureaucracy works) and so the project died. If you need a cure for insomnia, my talk with more details of how the project worked is here (skip to 7:28):

This then is the real frustration that I, and many other physicians have with EMRs and other Health IT systems. Can you just imagine how much further we would be if all areas of the Province had what a few isolated regions (like mine) have?

For COVID19 for example, our Covid Assessment Centre is on our EMR which means that I get an automatic notification if someone goes for a test. And if that test is positive, it allows for quick notification of the family physician so we can begin the process of contact tracing. It also allows for easy transmission of information of people with febrile respiratory illnesses so that we can track important information like when the symptoms started and ended.

Dr. Irfan Dhalla wrote an exceptional piece in the Globe and Mail on preparing for the winter in times of COVID19. Unsurprisingly, he called for reducing “untraced spread” of COVID19 (50% of all cases have no known contact) and a large part of that solution is a technological one, namely the Canada COVID alert app (available at both the Apple App Store and the Google Play Store).

While he’s correct about that, the reality is that we have more illnesses that we have to deal with than just COVID19. We need to be able to manage cancer, other infectious disease, heart disease, diabetes, the frail elderly with multiple problems and much more. The better we manage those illnesses, the more we can keep those patients out of hospital, which is great anytime, but particularly when there is a risk of hospitals being overwhelmed by a pandemic.

Again, in our neck of the woods the Home Care case co-ordinators are on our system. I often get messages from them about how one of my patients is doing, and requests for information from them (so much easier than faxing). This allows me to remotely address concerns patients are having sooner, and for frail patients, getting treatments sooner can often prevent a rapid deterioration, which will of course, prevent a hospitalization.

So while I really am glad that many more physicians will have access to PrescibeIT, I reluctantly point out that in its current iteration it only does about 65% of what our solution does. I suppose that’s better than 0% which people had before, but it is a testament to the failure of a wide swath of health care bureaucrats over the years that this is the best we have.

Even our system is not perfect. I get miserable situations like some of my COVID19 results come in through OLIS (Ontario Lab Information System) and others through HRM (Hospital Report Manager) and yet others get faxed (!) to me. The auto-categorization in HRM is really a complete joke. I dictated a note on one of my hospital inpatients, and the system classified me as a combined General Surgeon, Anaesthetist and Paediatrician – and while I’m glad the system thought I was that smart, the reality is I now have to go through all this data and spend extra time categorizing it properly.

eHealth Ontario, Ontario MD, Health Quality Ontario, the Ministry of Health and its various digital health teams were all to work co-operatively to build a strong Health Information System. But the reality is that these individual systems do not share information in a way that benefits patients.  The shared vision for health IT in the province (integrated health systems IT) still only exist in pockets around the province. There are lessons to be learned here and steps that should be taken.  All of which would really be beneficial now as we head into a potential second wave of COVID19.

Which leads this old country doctor to wonder: If knowing that a potentially huge crisis is coming our way in health care, will no one step up with a vision to fix Health IT Systems and Integrate Health Care information once and for all? And if not now, WHEN?

Don’t Like Mob Rule? Then Work to Fix Inequality

The past few months have seen a tremendous wave of social unrest in the United States, and some in Canada. This was spurred by the killing of George Floyd, an act so heinous that even noted racist Donald J. Trump called it a terrible thing. A seemingly endless stream of video evidence of discrimination and violence against not just Black people, but BIPOC (Black, Indigenous, People of Colour), meant these protests have carried on for months, and even threatened to end the seasons of professional sports leagues.

While the protests have largely been peaceful, there has been violence in some American cities. Additionally, many American protestors have taken to tearing down statues of those who they view as oppressive or racist historical figures. Canadians were confronted with this happening on our own soil when the Coalition for BIPOC Liberation tore down a statue of Sir John A. MacDonald in Montreal.

Reaction to this act in Canada was pretty swift and, sadly predictable. Numerous people have decried the action as “mob rule”. Media types who work for outlets with a penchant for Islamaphobia compared the protestors to the Taliban. What better way to both vilify protestors whose philosophy you don’t agree with, than by using dog-whistle type comparisons to get at Muslims you don’t like as well. Kills two birds with one stone, right?

Even our own inept Prime Minister, Justin Trudeau, stated that “actions like this have no place” in Canada. Of course we all know what he truly thinks of indigenous people by the way he brazenly attacked his former Justice Minister Jody Wilson-Raybould. Even the pro-Liberal Toronto Star criticized him for it. As for what he thinks of people of colour, well……

The usual argument against these protestors is that they should protest peacefully instead, and of course that allowing this “mob rule” will mean the mob will “come for you and your family” next. Not being satisfied with just going after Muslims, the extreme far right anti-BLM crowd throws in a nice dose of anti-Semitism as well, by suggesting these actions are funded by George Soros.

Generally, there are two types of solutions presented by those who claim they don’t want “mob rule”. The first is to demand a strong response. “Law and Order” is needed they scream. “Keep arresting people until there is no one left to lock up!” Peaceful protests are ok in their eyes (not a peaceful protest like cancelling some basketball games, of course, that’s just wrong), but the tearing down of statues is anarchy and must be met with force.

Many of these indignant types forget that the first tearing down of statues in America happened five days after declaring independence, on July 9, 1776. A “mob” in New York tore down the statue of King George to protest his oppressive rule and unfair treatment of Americans. Sound familiar? Undoubtedly the British viewed such an act as anarchy. Funny how those opposed to the protests don’t mention this.

The second solution offered is one that is promoted by people like Christian Walker (son of former NFL player and Trump supporter Herschel Walker, who is Black) and Sheriff David Clarke (also Black). Their suggestion is that to avoid brutality, one should show follow directions from the police, and learn to respect to the police and institutions. “When a cop gives you a lawful command, OBEY IT.“thunders Clarke.

However, not 30 minutes after reading a Facebook post in which Clarke is quoted as saying “if you want to protect your child, teach them respect”, I came across the following article on TMZ. Have a look at the videos. In the first video, a white man is doing anything but showing respect to the police officer. He is hurling insults, being threatening, using abusive language and doing everything that Clarke and Walker say you should NOT. While the police officer has his gun out (and I would say understandably, given the circumstances), there is no shooting and the individual is talked down.

The second video, is jarring. A black man is doing EXACTLY what Clarke and Walker suggest. He is standing quietly, not resisting, hands on his head so that the police can see that he is making no sudden or threatening movements. In short, he is co-operating, following the rules, and, as Clarke directed, obeying the police. His reward? To be viciously assaulted by a cowardly drop kick to the back.

And that one comparison symbolizes why the protests are happening. Despite doing what you should do in a lawful society, and following the rules, people are still being targeted for being BIPOC. That’s just the physical violence. All sorts of evidence exists that there is economic discrimination against BIPOCs.

Now to be clear, I am not a fan of violent protests or mobs. Mobs do destabilize society and can cause tremendous unrest, economic damage, and physical harm to innocent people. It’s imperative to find a way to stop them.

But stopping them also means acknowledging the reality that mobs and protests like these only happen because the way society is set up leaves a group of people feeling as if they have no hope for a better future. American Revolutionaries tried to legally express their grievances with England about not being treated equally to other British subjects for years prior to taking violent action. BIPOCs have been asking for true equality for decades (if not centuries). The reality is people usually only turn to violence if they have tried all other methods, and, if they feel there is no hope of a better future. It’s the despair that drives this behaviour and it’s the despair that must fundamentally be treated.

We must prevent “mob rule”. Doing so is the only way to preserve a safe, healthy and strong society. But doing so requires all of us to take a good hard look at persistent inequalities in our society, work to fix them, and thus give hope to people who currently feel none.

History teaches what the alternative is, and we don’t want to go there.

Four Years Later, What’s Changed at the OMA?

This past weekend marked the fourth anniversary of the defeat of the 2016 tPSA (tentative Physician Services Agreement) at the Ontario Medical Association (OMA). It marked the culmination of the efforts to mobilize almost 2/3 of the membership to vote against the deal, despite heavy pressure from the then Board to approve it.

In the aftermath of that agreement, there have been some significant and rather seismic changes at the OMA, and it’s worthwhile looking back to see what’s different, and what still needs to be done.

What’s Different?

Many of the more vocal critics of the OMA from the past have actually become more involved in the OMA. Heck from Dr. Shawn Whatley (2017) onwards, all of the Presidents of the OMA have been people who took a much more different approach to things than Presidents in the past. Frankly, that’s been good for the profession despite whatever tension it may cause at the OMA. Current President Dr. Samantha Hill and President-Elect Dr. Adam Kassam appear to be carrying on this path (which is good).

The Presidents are elected by Council, not from the Board like previous. It’s important to ensure that the President is not elected by a small group, and I’m glad to see it’s being proposed the President will be elected by the members going forward. The Board must listen to the President, because they represent the will of the members.

There has also been a significant shift in how the OMA is structured. In the past the OMA had something like 50-60 committees, all of which were chaired by a Board member. This led to the Board being too operational. Now the Board is down to four committees (Finance, Human Resources, Governance and Strategy) in keeping with the oversight function a Board must have. The total number of committees have been reduced to about 15.

The CEO, Mr. Allan O’Dette, has made a number of operational changes as well. He has brought in a number of cross-functional teams (essentially teams with members from each department) to deal with issues. These efforts paid off in fighting for changes to Bill 10, and the push to bring back arbitration after the government took it away. However, clearly the biggest impact of this approach was in how the OMA handled the COVID-19 pandemic.

I can tell you that I have never, ever seen so much praise for the OMA as I did around the COVID-19 response. Led by Dr. James Wright and Dara Laxer from the Economics, Policy and Research arm (and supported by just about everybody else in the organization – too many to mention but always in my thoughts with immense gratitude) they provided physicians with education, support, resources and timely updates.

I don’t believe the OMA could have mounted a response as strong as this if it was still structured the way it was in the past.

What Still Needs to be Done?

First and foremost, the last set of governance changes endorsed by the Board, must pass through Council. These changes will result in (most importantly) a reduction in the size of the Board from 26 physicians to 8 physicians and 3 non-physicians. Having been on the Board for the past 2.5 years, I can tell you first hand that it is extremely difficult to have a productive meeting with such a big Board. A leaner Board, with some true professional Board members to guide them can dramatically increase the productivity of the Board, and allow the Board to focus specifically on membership wide issues.

The restructuring of the Council to the General Assembly (GA) similarly is essential to the proper functioning of the OMA. The biggest selling point to me, of the GA, is the creation of the Working Groups. In the past, Council would appoint committees but they would be made up members of Council. Now, the Working Groups can include members of the entire profession. So if you have an interest in a specific policy, you don’t have to run for the GA. You can just go into a Working Group, and focus on your area of expertise. It’s a great way to broaden member engagement by allowing members to participate in areas of interest to them, and not take on the full responsibility of a GA or Board member.

The COVID-19 pandemic, and the resulting change to Spring Council delayed these changes, but we need to get them passed.

I will say, that while culture change is occurring, there is always the danger of falling back into bad habits. For example, the OMA staff (who I will say have really done an excellent job on multiple issues) will probably continually need to be “nudged” to focus on skills based recruitment. If the OMA sends out a call for members to join a specific committee, it is human nature to look at the applicants, and then pick people you already know because of their “institutional knowledge”. But the reality is that to serve members best, it is often important to pick new and different people, who also bring a broad set of skills to the table. It’s a hard change to make, and we must guard against slippage into old habits.

The OMA must continue to get bolder. Heck the Mission Vision and Values of the OMA clearly states that the organization will be bold, and will courageously pursue new ideas and solutions. Part of being bold, is taking risks. Again, there has been progress on this front at the OMA, but when you are historically a risk averse organization, it’s easy to take the path of least resistance on issues.

Finally, the last little bit of what has to continue to happen falls, quite frankly, on the rank and file members. Over the past few years, there has been a gradual increase in the number of members who vote in elections. This is a GOOD thing of course. However, we always need more members voting, and frankly, members need to THINK about who they are voting for.

Are you voting for someone just because they seem to spam you inbox/twitter feed/facebook page with and seem to “want it”? Are you just picking alphabetically the first candidate so that you can just get the damn website to go to the next page so you can finish off your renewal of membership? Have you actually read the position statements and seen the videos?

This year in particular, if the proposed changes do happen, it will be absolutely imperative for members to pick the right candidates for the Board and the General Assembly. Read all the position statements. Find the candidate you identify with. Then vote for them.

The OMA’s transformation is happening, slower than many would like, and often times with two steps forward and one back, but it is happening. To continue to make progress, the members will need to do their bit.

This blog was inspired by Dr. Graham Slaughter, who reminded me of the fourth anniversary. Graham is one of the smartest people I know, a exceptionally dedicated father and husband, and has been a tremendous help help to myself and others behind the scenes. Pictured with his new daughter Nora.

The “Feminization” of Medicine has Widened the Gender Pay Gap

Dr. Michelle Cohen (pictured left), a family physician from Brighton, Ontario guest blogs today. Opinions are hers (although in this case I share them). This article was initially published in the Medical Post and is reproduced here, with her permission, so that it is “ungated” and available for all.

What happens when certain types of medical work become synonymous with women’s work?

Women have moved into medicine in huge numbers over the past four decades. This is usually viewed as a good news story of social progress in a profession that had either banned or severely restricted female entry well into the 1960’s.

In this excellent paper by Dr. Elaine Pelley and Dr. Molly Carnes, the authors begin with a discussion on gender segregation in the broader workforce (in the US). It generally decreased thought the 20th century  with the entry of women into the workplace, but then stalled in the mid-90’s and ticked back upwards slightly.

When a large number of women enter a previously male dominated occupation, it will quickly move towards female predominance. This phenomenon is known as “tipping” and it has not been shown to happen in reverse (i.e., men don’t tend to take over fields seen as “women’s work”). When an occupation hits the gender tipping point (which varies roughly from 13-45% female), entry of men rapidly declines. This is the pattern demonstrated by teachers, secretaries, bank tellers, etc.

In academia and professions requiring high educational attainment, a tipping phenomenon occurs at 24% female. In other words, once a field is one quarter female, men start to lose interest in it. It loses prestige and the ineffable qualities granted by gender exclusivity.

What’s the evidence that a field loses prestige with female entry? At around the 38% female mark, interest from both men and women starts to decline. Research also shows an inverse relationship between how challenging a field seems and how many female PhDs are in it.

This is where we need to talk about the #GenderPayGap. Because not only do female dominated occupations earn less than male dominated occupations, historical data shows that each 10% increase in female share results in a 0.5-5% decline in earnings.

The gender pay gap is at its simplest about paying women less for equal work. But the gendering of occupations plays a major (and often overlooked) role. Research on high skill occupations shows men essentially take a pay cut when they enter female dominated professions.

This brings us to medicine. A profession with dramatic gender segregation among its specialties and little-to-no introspection on the impact of this phenomenon. In Canada, female representation among medical specialties varies from roughly 10% to 75%.

Historically, once women were allowed into medical school, they were immediately shunted into the specialties that seemed appropriate. Ones that involved babies or so-called “soft skills” like counseling. They were strongly discouraged from entering macho fields like surgery.

I say “historically” but of course, these ideas remain as strong as ever (that’s what happens when your industry lacks introspection on its own subculture). Ask any woman in medicine and she will tell you lots of stories like this one.

Naturally, we lack data on the gender segregation of specialties over time. If you can’t see a phenomenon, you can’t study it, right? Fortunately, Dr. Pelley and Dr. Carnes dig into historical data, showing that U.S. gender segregation in medical specialties has remained static since the 80’s—that’s my entire lifetime. American medicine has remained frozen in the same sexist ideas about women and men’s “natural” skills since the Reagan years.

Is Canadian medicine any better? We haven’t analyzed historical data (yet), but I think you know what I would say.

This paper does what few have: It looks at how feminization of a specialty impacts its relative earnings over time. This is such an important analysis and I can’t believe we don’t have more like these.

For example, pediatrics went from 22% to 63% female since 1975, but orthopedics has remained nearly the same. Subsequently, pediatrics went from earning 93% of the average MD salary to 71%. Meanwhile orthopedics went from 160% to 180% of average. Or consider obstetrics and urology. Obstetrics has lost relative income since the 70’s while going from 8% to 57% female. Meanwhile, urology has maintained its relative earnings (125% of average MD salary) while remaining at >90% male.

While I haven’t looked at historical data in Canadian medicine, I have done a lot of work analyzing the gender breakdown in specialties and their relative incomes. Those results will be published next month, but let me summarize it quickly now:

Gender segregation in Canadian medical specialties is a major factor in the gender pay gap. There are many other relevant factors at play, but the shunting of women into “female-friendly” specialties while discouraging entry into male dominated specialties plays a huge role.

We need more discussion on how women entering a field devalues it. We also need to broaden this analysis to include all of health care, which is full of women doing vitally important and shamefully underpaid work.

How to Feminism

The following is a guest blog written by Dr. Darren Cargill, pictured above Opinions are his. Especially what he wrote about Nik.

Like most of you I enjoyed Sarah Cooper’s savage tweets and parodies of Donald Trump during the lockdown.  From “How to Testing” to “How to Empty Seat,” she has entertained people around the world during difficult times.

But her tweets also got me thinking about feminism and the female role models I have had throughout my life and medical career.

Currently, the most recognizable feminist “role model” (stop laughing) in Canada is best known for firing our first Indigenous Attorney General and forcing out of Cabinet a physician who might been useful going through the COVID global pandemic.  He used his power and privilege to prevent them from speaking the truth about what actually happen.  He also yelled at a racialized MP who had chosen to step down, admonishing her for not appreciating all he, a self-admitted privileged white male, had done for her.  And his socks.

This doesn’t seem right.  Clearly, I am experiencing feminism differently.  If so, it seems like there is still lots of learning WE can do.  I needed to learn more.

So I did.  In the process, I read and heard a lot about something called the “gender pay gap.”  I didn’t know a lot about it, so I asked some colleagues of mine to explain it to me and what could possibly be done to remedy the issue.  

So instead of looking to our political leaders to set the example, I decided to look back at my own life and career instead.

First, I am very proud of the fact the Section of Palliative Medicine currently boasts only the second ever (damn you Genetics) all-female Executive for a clinical section.  As Section Chair for seven years, I have never had more confidence in the future leadership of our group.  This executive was not contrived or selected like some associations or cartels.  All three ran in open elections for our Section leadership.  Although we have had some great leaders for our Section in the past, our future has never been brighter.

One of my absolute favourite memories of the pandemic lockdown was Dr. Wendy Kennette doing an Executive teleconference from the Windsor Mobile Field House at St. Clair College in full PPE.  Nothing more needs to be said about her single-minded determination and commitment to compassionate patient care.  Except, it should be acknowledged that she also led the charge to create Windsor’s first permanent inpatient palliative medicine program at Windsor Regional Hospital. Dr. Pamela Liao has been exceptional in her first year as Section Chair.  She routinely leads from the front and regularly organized and participated in webinars to inform and educate members during the early days of COVID.  Finally, Dr. Patricia Valcke has stepped in as a first-time member of the Executive in the role Secretary/Treasurer after relocation from Saskatchewan to Ontario. She has hit the ground running as the new co-chair of the Schulich School of Medicine Enhanced Skills Program for Palliative Medicine, taking over from Dr. Sheri Bergeron.  I look forward to her bright future in leadership as well.  

Next, like most little boys, my first role model was my mom.  She recently retired at the age of 75.  She broke her leg in May, spent three months in rehab, most of that non-weight bearing, yet walked New York City by Thanksgiving (Canadian, not American for the record).  After all, she’s Dutch.  Wooden shoes, wooden head, wouldn’t listen, as they say.

I had many wonderful female teachers growing up.  But during elementary school, it was Helen, a fellow student, who pushed me.  We were rivals in elementary school, friends and colleagues in high school.

In university, it was Lisa, now a palliative care doctor of all things, who encouraged me to switch from Psychology to Neuroscience as an undergrad, and that maybe I should write the MCAT one summer, just for laughs.

In medical school, it was Bertha who took a chance on a woefully unprepared candidate who showed up to his interview high (as a kite!) on cough syrup.  It was also Danielle who joined UWO MEDS 2003 needing to change the world while the rest of us just hoped to pass.  It was my pragmatic roommate Laurie, who helped me to put life’s setbacks into perspective.

It was Charmaine, my first mentor in palliative care, who showed me that palliative care is not a job, its a calling.  It was Janet who encouraged me to give palliative care a second chance following my first experience with burnout.

It was Carol, as executive director for the Hospice of Windsor, who taught me how to lead from behind.  She never treated a single patient in her entire career, but she put dozens of people in a position to succeed, to the benefits of thousands. It is Colleen who has kept our Hospice organization afloat in turbulent times.

I think of Jane, whom I met ever so briefly at the CMA in Vancouver 2016.  She stepped up to make a difference and stepped away with her grace and dignity still intact. And Jody, who exemplifies integrity in times when it is sorely lacking in Canadian politics.

I think of Catherine who is the smartest woman I know, thus giving her only half the credit she deserves.  Secretly I think she enjoys letting us spin our wheels with a problem she had the answer to an hour ago.

I think of Nikki, who is the sister I never had, if you don’t count the seven I already do.  Nikki is gonna murder me for calling her Nikki. Probably on a Friday. (Hey Nik, it’s Sohail here – just a reminder, that Darren calling you Nikki, I would NEVER EVER do that!)

I look at Jacinda who didn’t just flatten the curve, she levelled it like an All-Black in a foul mood.

I look at Hayley, who seems destined to be an even better doctor than she was a hockey superstar. I think of Menon and Kim who inspired me the same as Felix and Marty.

It is all of the nurses, staff, volunteers and caregivers at the bedside of our palliative patients, night and day, without compliant, without fail.

It is my wife who was diagnosed with cancer at 29 and kicked its ass by the time she was 30, got married at 31 (to me, just in case you were wondering) and gave birth to a miracle child at 34.  She comes from a family of ass-kickers.

So, when people talk about the gender pay gap, I wonder, why that is.  Because its 2020, after all.  And much like the evidence for the benefits of palliative care, the avalanche of evidence for the gender pay gap is embarrassing.  The benign neglect to this problem is also similar.

Like all things, you need to start by educating yourself.  Here are some good places to start:

What’s driving the gender pay gap? (CMAJ, 2020)

Here is an article in the Globe and Mail (2019)

You can watch Dr. Audrey Karlinsky’s webinar

And Dr. Leslie Barron’s article

Make sure to keep your eyes out for OMA President Dr. Samantha Hill and Dr. Michelle Cohen’s upcoming article in CMAJ, coming soon.  As well, a Report to Council will be making its way to OMA members soon.  I humbly suggest giving it a read when it does.

Finally, for the men reading this:  This is not about taking something away from you.  It is about giving to them what they have deserved all along.

Respectfully,

Darren Cargill MD

ConquerCovid-19 a True Canadian Success Story

“Not all heroes wear capes.” – It’s an expression often found on the internet.  It of course, refers to the fact that you don’t have to be Batwoman or Superman or whoever, to do some good in this world.  

During the Great Pandemic of 2020 of course, this phrase is often used to describe those of us who provide health care on the front lines. Cleary, the physicians, nurses, first responders, PSWs, support staff, environmental services staff and many others who provide front line care during this historically difficult time are heroes.  They inspired me during my term as President of the Ontario Medical Association (OMA), and they continue to inspire me now with their dedication and passion.

While there are many other heroes out there, I want to give a shout to one group that in many ways represents Canadians at their best, ConquerCovid-19.  

The full story of how ConquerCovid-19 came to be can be found here. The short version is that they started out in mid-March as the brainchild of Sulemaan Ahmed and his wife Khadija Cajee.  They heard their physician friends complain about the lack of Personal Protective Equipment (PPE) in their clinics, and wanted to help.

Neither one of them is a stranger to advocacy for social causes. They both are already heavily involved in fighting the ridiculous No Fly list in Canada that erroneously lists thousands of children and innocent people.

Sulemaan, Khadija and four of their friends formed ConquerCovid-19 and using their business connections ( Executive Training with ServoAnnex) asked companies who had PPE to donate them to health care providers.  Almost immediately, their friends and their friend’s children volunteered to help out (with apologies there are too many to list).  The organization grew steadily and quickly.

Then a medical student who also was worried about the shortage of PPE heard about their endeavours, and offered to help out.  As brilliant as medical students are, normally one extra student wouldn’t cause a wholesale change.  But said medical student also happens to be the greatest female hockey player of all time, Hayley Wickenheiser.  Next thing you know, she gets her friend Hannibal King….Green Lantern….. Deadpool… Ryan Reynolds involved and the star power catapulted the success of the organization.

A quick look at the their twitter feed shows that they have donated PPEs to organizations that deal with at risk youth, medical schools, support services for frail seniors, nursing homes, multiple child and youth services, shelters for new immigrants and refugees, rural and remote areas of the province and much more.

What’s more, they suddenly found people willing to donate supplies other than PPE. Instead of saying no, ConquerCovid-19 took on Hayley Wickenheiser’s mantra (Get Sh-t Done!) and took non-PPE supplies and found good homes for them. Have some extra computer tablets – send them to nursing homes so residents can communicate with families. Feminine hygiene products – send them to Women’s Shelters, and much more. There has also been a significant amount of cash raised from sales of what Reynolds calls “a boring shirt”. Ok he was more colourful than that, but check out #boringshirtchallenge.

All of this was in addition to the almost 500,000 units of PPE donated to medical clinics across the Province in co-ordination with the OMA. I was honoured to have been invited their April PPE drive where I saw the group in action.

That’s when I realized the best thing about ConquerCovid-19.  They exemplify what Canada is all about.

It’s no secret that we are so living in a time where there is a tremendous, un-precedented call for social justice.  The Black Lives Matter movement has forced us to confront and deal with inherent systemic racism against Black Canadians. In particular, Statistics Canada data shows that we are failing yet another generation of Black youths. Alas there are too many such stories in Canada.

Our record in dealing with our Indigenous population is disgraceful, with even the United Nations calling the housing conditions abhorrent.  We have systemically discriminated against them, and there are too many individual stories to mention. There has also been a rise in Islamophobia and anti-Semitism.

Many will see this and despair for Canada.  Make no mistake, all of us need to continue to be vigilant and work to improve our country.  But when I think of Canada, I will, instead, think of ConquerCovid-19, and how it exemplifies what Canada is all about.

You see, Sulemaan and Khadija are Muslims whose families immigrated to Canada.  The leadership group (whom I was fortunate to meet) includes Jews, Sikhs, Christians and those that are, let’s say, ill defined when it comes to religion.  They have people of all colours in their organization.  

ConquerCovid-19 is not just a snap shot of Canada in 2020, it’s a snapshot of the best of Canada.  While we struggle to deal with our failings as a nation, rather than look with despair on our country, we should look to the hope that organizations like ConquerCovid-19 provide.  To my mind, there is no other country on this planet where such a diverse group of people could come together, find a common cause that is rooted in charity and selflessness, and work co-operatively for the benefit of all.

The strength of Canada lies in it’s unique multi-cultural nature, where our differences are celebrated, not denigrated. Where our basic humanity, tolerance and kindness is the common thread that unites us all. That is what Canada is all about, and that is what ConquerCovid-19 exemplifies every day by their actions.

Thank you ConquerCovid-19, for reminding us of the promise that is Canada.

Open Letter to Alberta Ophthalmologists

Dear Alberta Ophthalmologist,

I don’t practice in Alberta, and I certainly don’t know all the ins and outs of the Alberta Medical Association (AMA). But I, like every other physician in Canada, am horrified by what’s going on in your province. Your government has torn up a previously agreed to Master Agreement, and despite the attempts by the AMA to fairly negotiate with the government, your association has been ignored, insulted and treated with the most disrespect I have ever seen from a government, and I lived through the Eric Hoskins/Bob Bell years in Ontario!! That physicians are leaving work in your province is absolutely no surprise, and that patients will be the inevitable losers in all this, is entirely predictable.

However, I read with extreme concern when I read about the Eye Physicians and Surgeons Association of Alberta (EPSAA) offering to separate from the AMA and negotiate separately with the government. Sadly, I believe that whatever the internal political reasons behind this may be (let me take a stab in the dark and suggest it has to do with fee relativity and how you feel you are represented on that front), EPSAA is going to find itself played by the government, and you will all suffer after.

You see all of this mirrors exactly what Ontario went through a couple of years ago. We ourselves had something similar happen with the Ontario Specialists Association (OSA). They felt frustrated with the Ontario Medical Association (OMA) for reasons that are likely similar to yours. They thought, as EPSAA clearly does, that they would be better off negotiating separately with the government.

I warned the specialists that they were being played. In my blog, you’ll see I pointed out that in dealing with any militant government, they will use a split in the profession to divide and conquer, and that all physicians would lose out if they tried this.

The response from the Chair of the OSA, Dr. David Jacobs was to suggest that I was wrong in my concerns, particularly about our own Binding Arbitration Framework:

Full disclosure, I happen to like Dr. Jacobs. He’s passionate, smart, opinionated and when push came to shove, really helped the profession more than people give him credit for by publicly exposing the flawed 2016 Tentative Physician Services Agreement.

Despite my warning, he and the OSA persevered on their path however, and held a poll at the end of November, 2018 that suggested that up to 8 specialties wanted to separate from the OMA. And what was the first thing the government did in response to this? They of course, took away the Binding Arbitration Framework for EVERY PHYSICIAN in Ontario. It didn’t even take them two weeks to do that.

Now I would like to think I have a reputation for being very pro physician’s rights. Frankly, I hope to build on that more and convince those of you who may not feel that way that I am pro physician. But to be honest, I didn’t actually blame the Ontario government for trying to take away Arbitration. The reality is that when you are in a tough, difficult negotiation, you always look for weakness in the other side. The government sensed weakness, and so acted on it. Just like the Alberta government will on this move.

Thankfully however, the broader OMA as a whole immediately started a massive advocacy campaign that did result in the government realizing that the profession was maybe not as divided as they had hoped, and arbitration was returned. But the whole mess delayed the hearings that were in progress by a couple of months, and the effects of the delay were clearly felt in the shortened timelines for implementing the eventual Arbitration award.

I also need to point out that your current health minister, Tyler Shandro, is a……..um…….interesting piece of work. I seriously believed that I would never see a health minister as bad as Eric Hoskins from Ontario, ever. But while Hoskins was all kinds of awful and incompetent, at least he never went to a physicians house to berate them, causing that physician to fear for his families safety. Nor did Hoskins ever use his authority to access confidential information on physicians to call them.

Do you really think that Shandro will deal fairly with ophthalmologists, just because you propose to separate from the AMA?

I understand that you are unhappy with the AMA. I certainly spoke to many specialists (and family physicians!) who were unhappy with the OMA. But I guarantee you right now, that if you take this step, and fail to learn from the lessons in Ontario, you will be worse off than before.

The best way to fight a militant, un-co-operative government that seeks to vilify you is to stick together with your colleagues. You may not like what some of them say or do, but I guarantee you that you will be better off with them, rather than trying to do it against politicians and health care bureaucrats who have shown they don’t really care about you. To those politicians and bureaucrats, you are not partners (no matter what they say), you are simply tools and pawns to be used to promote an overall agenda.

I hope you don’t learn that lesson the hard way, like we did in Ontario.

Yours truly,

An Old Country Doctor…….