There Is No Substitute For a Doctor

Note: This blog was originally published on the OMA website.  It’s being reproduced here for those of you who do not access that site.  I have also added commentary on the report about the growth in physician numbers.

Every health care journey is different, but they all have one thing in common. They all involve a doctor. There is nothing pleasant about getting hurt or getting sick. But in Canada, there is something extremely comforting about knowing that doctors are there for us in our time of need.  Patients understand the value of doctors.  They understand that it takes a doctor to diagnose the problem, determine the appropriate course of care and follow them throughout treatment.

Doctors have a minimum of ten years of post secondary education before they enter the profession. They continue to enhance their skills throughout their practice through regular education programs. This training and expertise are what differentiates them from other health care providers. Many providers play a critical role as part of an integrated health care team, but it takes a doctor to identify – and often deliver – the continuum of care needed.

Ontario doctors are on the front lines of our health care system.  We care for 340,000 patients every day, and the health and well-being of those patients is our absolute number one priority.  We know what is working within our system, and we know what needs to be fixed.  We understand that changes being made to health care have to work for patients in real-life situations, and we understand better than anyone that cutting physician services means longer wait times and reduced access to care for our patients.

That last point is critical.  Ontario doctors carry a heavier workload than doctors in many other jurisdictions in the world.  We currently have 2.3 physicians in Ontario for every thousand people.  Europe has, on average 3.9 physicians for every thousand people, with countries such as Sweden and Germany up over 4 (source: World Health Organization’s Global Health Workforce Statistics).  Despite this heavier workload, and because of the dedication of Ontario’s doctors we still manage to provide the best possible care we can to our patients.

Not only do I want to preserve that, but I want to improve on that.  While I’m grateful to see the recent report that suggests the number of physicians is increasing faster than the general population, we still have a long way to go.  Europe also has many structural differences in how they deliver health care (some of which we should copy – a topic for another blog).  But even with those differences, they need more doctors per capita.

Research has shown that a high quality health care system needs strong physician leadership.  Specifically, physician leadership in terms of system design, governance, and implementation is vital.  A doctor-led system that focuses on integrated care provides better quality at lower cost, and this is what we need to build in Ontario.  The patient-centred system of the future, today.

Ontario doctors are willing to help build, and lead, the health care system that Ontarians deserve.  A system that will improve patient care and health outcomes and reduce wait times.  A system that will recognize and meet the needs of rural, Northern and underserved communities.  And a system that removes unnecessary administration and red tape to enable more efficient and effective delivery of care.  It takes a doctor to lead a patient throughout his or her health care journey, and it takes doctors to lead Ontario’s health care transformation.  Because ultimately, there is no substitute for a doctor.

My Experience With The Vaccine Hesitant

Dr. Samantha Hill

The following blog was written by Dr. Samantha Hill (pictured above), President Elect of the Ontario Medical Association.  The blog reflects her opinion and not that of the OMA.  It was published in the Medical Post, but is being republished here for those who do not have access to that site.

It’s an interesting experience, being yelled at by a room full of angry people.    It’s not something physicians encounter regularly.   Professional criticism is usually subtle: askew glances, rejected papers, absent promotions.  Decades of schooling had not prepared me to stand in a room full of people yelling “shame”.

On Monday, I (and others) deputed at the Toronto Board of Health on the merits of vaccination.  We were met by a large crowd of angry people.  I was heckled, jeered at, and even photographed for later attacks on social media.

The aggressive opposition was unexpected, especially when presenting on something as factually obvious as vaccines.   Among doctors, this isn’t a debate.  We KNOW the benefits outweigh the risks.  We know it more certainly than we know many other things in medicine.   Vaccines work.  Vaccines are safe.  Vaccines are vital to our communities’ well-being.

“Liar, you’re all just in it for the money”, someone yelled.   I was angry, defensive, and incredulous.  And above it all there was a sense of surrealism, surely this can’t be real?

But sitting in town hall for 5 hours listening to a crowd of passionate parents and advocates beg that they be allowed not to vaccinate their children I had time to work through some of that.  I had time to get past my perspective and reactions.  So I listened.  Prior to speaking (and being identified), I exchanged smiles with the mother nursing her infant to quiet them, with the mother patting her young daughter’s head while she colored quietly, with the two boys a little older than my eldest who after a few hours of sitting were getting antsy.  There were no smiles after I spoke.  But still, I listened.

A young lady, presented to the Board passionately about bodily autonomy, scholastic freedom, and freedom of choice. While I disagree with her stance entirely, I was, in an odd way, proud of this fierce young woman. She was clear and articulate and witty. I wanted to congratulate her on her activism, on her bravery, on questioning authority figures. I wanted to tell her how impressed I was, and how I was sure she was going to be successful in life, a voice for change, a voice for those who might need help finding their own. But that would have been inappropriate and likely unwelcome. And my heart broke a little, that I as a female physician couldn’t offer this mentorship and support, that in this critical space, doctors were neither trusted nor respected.

Another woman pleaded with the Board to find compassion for those gathered, who sought only to protect their young. And I wondered, how do you tell people who are so certain, that the actions we take that they oppose, are in fact borne out of compassion? Compassion for all the children at risk by being unvaccinated? Compassion for bereaved mothers of children now deceased from preventable infectious diseases? Compassion for cancer patients who are already fighting for their lives, that they not be subjected to yet another battle? It would be perceived as paternalistic and demeaning.  My heart broke a little more.

I heard people decry feeling silenced and coerced, being thought of as uneducated or uninformed. Mostly, though, I heard fear. Profound soul-shattering fear. The instinct to protect our young from a perceived threat is deep-seated; this is a fear that doesn’t allow for logic, or rationality.

Suspend your medical training, your knowledge for a moment. Imagine being cornered, feeling that the doctors and nurses were out to hurt your child, that the government was complicit and supporting them, that YOU were the last line of defense for your children from absolute inevitable severe harm. Imagine that for a moment.  Stay in that place.  Become uncomfortable.  In fact, the horror must be untenable.  I was a parent before I was President-Elect of the OMA. I would stand in front of a firing range for my children. My heart breaks entirely.

It’s an easy stance, being firmly on the side of science, insisting that population health supersedes individual choice.  In fact, I salute the Board of Health on taking a leadership stance on this issue.  It’s hard to hold a space of compassion for the “anti-vaxxers”, to remember that behind their hurtful words and upsetting actions, they are simply terrified and angry parents trying to do their best for their children.  But as I walked away from town hall on Monday, my broken heart demanded that I try.

 

 

 

 

 

 

 

The Facts About Vaccines

Note:  The following blog was published yesterday on the Ontario Medical Association website.  It’s being reproduced here for those of you who don’t go to their site.

Labour Day has come and gone. The kids are back at school (Woo Hoo!). This seems like the right time to talk about vaccines. For children. For adults. Vaccines protect us all.

Most vaccines come in the form of needles. A few are administered orally or nasally. They protect people against certain diseases and infections. Many of the diseases they prevent are extremely serious, and extremely contagious. It only makes sense that we should all protect ourselves, and at the same time protect others. For children here in Ontario to attend school, they must be immunized against several infectious diseases.

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Not everyone is comfortable with vaccination. Some people make claims about vaccines that are simply not true. Others hear those claims, and become afraid. They refuse to have their children or themselves vaccinated. This is dangerous, for them and for others. Which is why, I would like to present the facts about vaccines.

Fact – Vaccines are safe
It is true that vaccines can cause some side effects, such as headache, mild fever or muscle aches, but for the most part they are minor and quickly go away. You are much, much more likely to become seriously ill from a vaccine-preventable disease than from a vaccine, and the benefits of protecting yourself and those around you far outweigh any potential risks and side effects from vaccines.

Fact – Vaccines do not cause autism
There was one study, more than 20 years ago, that suggested vaccines cause autism. It has since been thoroughly discredited. The author has PERMANENTLY lost his licence to practice medicine. There is not a single piece of evidence linking vaccination and autism.

Fact – Vaccines do not give you the disease they are supposed to protect against
Some (not all) vaccines do contain live versions of the germ that causes the disease, but the germ has been so weakened that it poses no danger for anyone with a healthy immune system. And these vaccines are not administered to people whose immune systems are not healthy.

Fact – It is perfectly safe to receive multiple vaccines at the same time
Your immune system is constantly handling exposure to many things at once. Multiple vaccines do not cause problems for the immune system, and getting several vaccines at once means fewer trips to the doctor for you.

Fact – Vaccines are not only for kids
You are never too old to catch a disease, and you are never too old to get vaccinated.

Fact – If everyone stopped getting vaccinated, rare diseases today such as polio and measles would come back quickly
Polio and measles have been made extremely rare because of vaccination. Let’s keep it that way. If we get vaccinated, and our children get vaccinated, we might even wipe these diseases off the face of the earth.

Fact – Vaccination helps everybody
When the majority of a population is vaccinated, there’s little opportunity for an outbreak. This is called “herd immunity”: the entire population is more protected, including infants too young to be vaccinated and those with weakened immune systems like cancer patients. It is important that those who can be vaccinated get vaccinated to help keep everyone healthy.

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For physicians like me, vaccination really does fall into the ‘no-brainer’ category. Doctors would always rather help their patients avoid a disease than help them recover from it. Which is why the fact that there is any disagreement at all about the safety and importance of vaccines is such a frustration. Hopefully, I’ve been able to help.  Please spread the word. Billions of people around the world, have been protected through vaccination. But that’s not good enough.  We want to protect more.

If you have any concerns about vaccinations please speak with your doctor. There is no substitute for your doctor. Your doctor has the expertise and evidence to help you understand why vaccinations are critical, and what the risks are of not vaccinating your children.

Communities Can Play a Role in Physician Recruitment and Retention

Note:  This blog was originally posted by myself on the OMA website.  It’s presented here as for those of you who don’t go to the OMA site.

Earlier this month I was pleased to have an opportunity to speak to municipal leaders from across Ontario at the Association of Municipalities of Ontario (AMO) conference in Ottawa.  I talked about how small and mid-size communities can play a significant role in attracting and retaining doctors.

Family doctors are the gateway to the rest of the health care system, and many communities don’t have enough of them (or specialists).  We’ve all heard about small towns losing one or two doctors in a short period and then scrambling to attract replacements. More doctors where we live means fewer sick days, stronger economic growth, and longer, healthier, happier lives.

What can municipalities do to attract and retain doctors? Start with making succession plans with your local doctors sooner rather than later. You can also encourage them to take on medical residents – ‘trainee doctors’ who need to work under the supervision of an experienced physician. If you give residents an opportunity to live in your community for their education, they just might stay.  This is what happened to me.  I spent two months of my training in small towns, and came to love the lifestyle and the style of practice.  Now I practice in Stayner, which has 4,200 people.

Small and mid-sized communities are some of the best places in the world to live. Community-minded purpose, cheaper real estate and rent, easy access to the great outdoors, and friendly and welcoming people is a big competitive advantage. Twenty-seven years of practice in Stayner, and I still feel the same way.

Once the trainees are in your community, make them feel at home. They’re looking for a community and a lifestyle, and not just a job. Work with local businesses to create a great welcome package, like a complimentary pass to the YMCA, local parks and attractions. Make sure they’re invited to community events. Anything to get this excellent talent feeling at home and feel like they are part of the community. You want them to envision putting down roots.

As the provincial government sets out to transform Ontario’s health-care system and implement Ontario Health Teams, strong local health care has never been more important.  The Ontario Medical Association has been working closely with the Ministry of Health to deliver the best health care possible to every resident in Ontario. To help support these changes, your community needs health care infrastructure. The top-of-mind definition of infrastructure – like sewers and roads – usually heads the list in the planning process. It’s equally important to ensure that health care infrastructure keeps up with future demand – and at limited cost to taxpayers.

Ontario’s Planning Act allows municipalities to require community benefits from developers where their projects exceed local zoning by-law densities. Traditionally, this funding is earmarked for projects like street improvements, playgrounds, daycare spaces, or affordable housing. These are all important, but as communities grow, appropriate commercial space will be needed to welcome and encourage new health care practitioners and facilities. This could be a physician’s clinic, or an office for the new Ontario Health Teams.

While health care is largely a provincial responsibility, the message I wanted to get across in Ottawa is that municipalities can and should play an important role in shaping their own health care future.

During my time at AMO it was interesting to hear about the innovative steps communities have taken to successfully attract and retain doctors. We would love to hear what strategies have worked in your community. Let us know via the OMA social channels.

Health System Reform Must Include Physicians

Wright

The following was written by Dr. Jim Wright (pictured above) and Dr. Adalsteinn Brown. I found the blog very thought provoking.  Reproduced at their request and with permission.  Opinions, are theirs.

Ontario has embarked on a bold experiment to transform care with a large focus on Ontario Health Teams or OHTs. At maturity, OHTs will be responsible for the full continuum of care within a community. As the Premier’s Council’s latest report suggests, OHTs should be able to provide an integrated experience for patients, an experience that takes advantage of the latest digital technologies to deliver care where and when patients need it, and that relentlessly improves against the quadruple aim goals of better population health, better cost, better patient experience and better provider experience.

This is a laudable vision and one that is long overdue in Ontario. Several health systems have already begun experimentation, implementation and even evaluation of these sorts of integrated models of care. And while no model of care is a panacea, there are some limited but encouraging signs from these other systems. The history of health system reform, however, in Ontario is one of largely excluding physicians from leadership. So, an important question for physicians in Ontario is how to respond to the OHT reforms. In this blog we consider this question and make some suggestions around the hows and whys of physician engagement in these reforms.

First off, it is important to state the obvious; Health system reform must include physicians. Physicians remain responsible, with their patients, for most decisions around care. It is hard to expect a system of care to change unless that reform engages and works with the physicians. Moreover, the importance of physician (and all clinicians) in reform is clear. One of us has argued previously that clinician engagement and leadership is one of the three must-haves for any health system undergoing reform and is more important than the typical Canadian paths to health system reform like regionalization, electronic medical record implementation, or compensation structures.

Perhaps as importantly, early evidence from the US and the Accountable Care Organization (ACO) experiment where communities of providers come together to take care of defined populations suggests physician leadership is key  to success. Those ACOs that had physician leadership (and particularly primary care leadership) tended to do better. A recent supplement to the New England Journal of Medicine focussed on how to build strong physician leadership in ACO type models.

The ACO experience is important because it is based on a model of risk or gain-sharing where ACOs become responsible for the care and the costs of that care. As care improves, prevention increases and patients are able to stay at home or in the community, ACOs share in these savings. In some models, they can also share in the losses. How should physicians engage with these sorts of models? With this question, it is important to parse carefully the evidence and the OHT model. The first conclusion is that individual physicians should not face risk or gain-sharing on their own patient populations. Although OHTs will manage hundreds of thousands of patients, individual practices will not be large enough to manage risk. One very ill patient could change the cost profile of an individual physician’s practice and we do not want to encourage reforms where physicians are punished for taking on the sickest and most vulnerable patients. Experience with other reform efforts suggests that these sorts of approaches can leave patients without necessary care.

If not risk or gain-sharing on their own patient populations, then should physicians face a pay-for-performance type system where they are encouraged to provide certain types of care or discouraged from other types of care? Again, the conclusion is no. Repeated Cochrane Collaboration reviews have showed a lack of evidence to support pay-for-performance. Although a number of Canadian provinces have implemented pay-for-performance schemes, these have tended to buy small amounts of change in process without impacting outcomes or larger goals like sustainability or equity. In addition, P4P shifts the activity from improving integration to one of compensation. Finally, P4P also inevitably focuses on the metrics rather than the goals of the reforms. Instead of focusing on improvements in the system, P4P often leads to arguing against the metrics.

So, if physicians should be engaged and should be part of OHTs, but should not face risk-sharing or pay-for-performance at an individual level, then how should they participate in OHTs? It is important to remember that OHTs are a new form of organization in Canadian healthcare. Physicians can and should be part of and help lead these organizations. But any incentives they face and any thoughts about risk and gain-sharing should reflect the success of the organization, not of an individual within that organization.

The alternative to gain/risk sharing is to view the improvement in the health of populations, improved quality of care and enhanced integration are incentive enough to encourage doctors to participate in OHTs and change their practice. Doctors want to do the right thing for their patients. Furthermore, enhanced integration will relieve the administrative burden for doctors, should improve their productivity, and most importantly, allow them to spend more time directly caring for patients. Any financial gains of OHTs instead of accruing to doctors could instead be invested in patient care, such as enhanced IT systems or patient navigators and spread out over necessary improvements (and increases in care).

This means that performance measurement and reporting is key. Performance indicators of what we want to achieve in this reform, grounded in the quadruple aim, will be critical. This will also help physicians see and stay focused on improvement. It also means that stronger financial management is key. Without such management, individual OHTs will not be able to prioritize investments in better care. Finally, it re-enforces the importance of physician engagement and leadership. Without it, we risk losing the connection between better system management (and improvement) and the decisions made at the front lines of care.

Although not all will agree, for doctors, health care reform should be all about improved care and integration for all and not about financial gain (and loss) for some.

James Wright is Chief, Economics, Policy & Research at the Ontario Medical Association

Adalsteinn Brown is Dean and Professor at the Dalla Lana School of Public Health, University of Toronto.

Ontario Health Transformation Needs Strong IT to Succeed

Ontario has recently embarked on what has been described as the biggest transformation in health care since Medicare.  Central to this transformation are the development of two new organizations.

The first is Ontario Health.  Ontario Health amalgamates numerous separate agencies (all 14 LHINs, Cancer Care Ontario, eHealth, etc.) into one large corporation.  The goal is clearly to reduce the duplicate back end administrative costs (separate payrolls, HR departments, workplace policy and procedures and so on) and create an integrated agency with seamless and consistent policies.  As someone who was a fierce critic of the previous LHINs, I can’t help but be pleased at this move.  (It was also recommendation 3 I made to then Premier Kathleen Wynne on how to fix health care).

The second move is to create Ontario Health Teams (OHTs).  In broad terms the goal of the OHTs is to ensure that doctors, hospitals, home and community providers work together as one co-ordinated team to help patients.  The OHTs stated goal is to integrate care around the patient.

The concept of OHTs is certainly a good one.  There is plenty of evidence that suggests integrated care is good for patients.  Jenny Grant (from McKinsey and Company) wrote about the benefits of integrated care (particularly for patients with chronic disease) and pointed out:

  • Sweden reduced the need for hospital beds after introducing this model
  • Sweden also reduced the number of “delayed discharges”
  • A reduction in hospital admissions AND lowered patient costs for patients in Geisinger’s Medical Home Program
  • A 79% reduction in wait times for social care assessments after Tobray Care Trust introduced the model

Given numbers like that, it’s no wonder that the government is exploring this model for Ontario.  Physicians also support the concept of integrated care because at the end of the day, we want what’s best for our patients.  We will always support policies that provide good health care (and we will always criticize polices that disadvantage patients).

What’s needed however is to turn that concept into a truly functioning entity.  These models be voluntary, physician led and primary care based.  In order to do that, there are two absolute musts that the OHTs require to be successful.

First, the OHTs must have strong physician leadership, particularly at the governance level.  Greg Scrine from Lumeris said it best regarding the American version of integrated care (the Accountable Care Organization):

“Physician engagement is the key to the success of an ACO, and consequently the efforts of setting up an ACO need to be physician driven to achieve the desired results.”

In Ontario, this does not seem to be a problem.  The Ontario Medical Association (OMA) has held several town halls on what OHTs are, and over 800 physicians participated.  There is keen interest in this model from leading family physician organizations like the Section of General and Family Practice of the OMA as well. So long as the government wants physician leaders, it appears they will have them.

The second essential component of a successful OHT is a robust health IT system that integrates seamlessly with the various organizations that support patients.

“In order to achieve benchmarks, ACOs rely on a strong population health technology infrastructure (and rely on EMRs to bridge this)” – Healthpayerintelligence.com

To put it charitably, Ontario’s current IT health infrastructure is a mess.  In the past 15 years, the government seemed to have absolutely no vision for an overarching health IT system that would put patients at the centre of the system.  We currently have three main hospital IT systems, about 7 physician-based EMRs (electronic medical records), multiple pharmacy systems, a home care system and a nursing home system, and none of them co-ordinate with each other.  Add in a multitude of radiology systems, and a separate system for all sorts of allied health care providers (Red Cross, St. Elizabeth, etc) and you essentially have a potpourri of systems, that unfortunately when put together emit an odour reminiscent of Pepe LePew.

Thankfully all is not lost.  The current government is taking a measured, thoughtful approach to the formation of the OHTs.  The first thing they are doing is introducing a Provincial standard for interoperability. Essentially this would be a secure format that allows, say, hospital IT systems to talk to Physicians EMRs and then to home care and nursing homes.  I suspect some legislation will be needed to force IT companies to adopt this standard, but it is long overdue and I’m glad the current government is finally implementing this.

The next step is where some challenges lie.  One of the goals of the current health care transformation is to allow patients to have more access to their records.  Several hospitals already allow this.  The issue is that different hospitals use different portals to allow access.  I’ve also seen some physician EMRs allow this, of course, all using their own portals. The last time I counted there were something like 70 Apps right now that purport to allow patients the ability to access their charts.  Clearly, there needs to be just on Province wide patient portal that allows patients to access their information.

To do this the government should simply partner with an organization that develops the patient portal.  Obviously, the organization could not be a for-profitentity (more to ensure privacy of data as opposed to any anti-capitalist sentiment on my part).  This would ensure that everyone in Ontario could use the same software to access all their records, and allow the seamless integration necessary for OHTs tosucceed.

There have been big changes in health care the past few months, with much more to come.  Thankfully the Premier’s Council on Ending Hallway Medicine is led by Dr. Reuben Devlin, who has a strong history of supporting IT to enable better health care.  Hopefully, the government will see the benefits of using a single Provincial Portal as a means of enabling the success of the OHTs. This would be a benefit for all Ontarians.

ONE MORE PATIENT SEEN – ONE LESS PATIENT WAITING

Note:  This blog was originally published on the OMA website.  I’ve reproduced it here, for those who don’t normally go to the website.

I am proud to be the President of Ontario’s 31,500 practising physicians. I know that making sure every patient gets the care they need, when they need it is every physician’s top priority. We are on the frontlines of the health care system, caring for almost 340,000 patients every day.

Ontario is undergoing a much needed, and absolutely necessary health care transformation. Our population continues to grow and age and people’s health care needs are increasing in their complexity. All across the province, doctors are working hard to care for more patients and reduce wait times.

Under our health care system, doctors are independent contractors who own their own practices and operate as small businesses. Physician services depend entirely on patient need, and that varies from community to community, specialty to specialty, and physician to physician.

Doctors bill for patients they see, procedures they perform, and in some cases, the tests they interpret. It is important to note that the amount a doctor bills is neither their salary nor their take-home pay. Physicians must pay for the costs of operating their practices, from staff, to rent, to medical and office supplies. These expenses take up a significant proportion of billings, in some specialties up to 50%.

There are also many different models for practices. Some are small and have limited staff while some have a much larger team of several types of health professionals including: physician assistants, nurses, nurse practitioners, technicians and medical assistants. Expenses and volumes of patients seen would be very different depending on the operating model.

A physician’s annual gross billing amount reflects demand for treatment. The more patients need services, the more OHIP is billed for those services. This demand may be intensified in remote and rural locations where there are limited medical resources. In fact, many physicians in underserviced communities may work 7 days a week to provide the best care for their patients.

It is also important to note that Ontario continues to have a lower number of physicians than most other jurisdictions in the world. We currently have 2.6 physicians for every 1,000 patients, whereas Germany has about 4 physicians for every 1,000 patients. This means that our physicians have to see more patients (and thus bill more) to help keep the residents of Ontario healthy.

The OMA  (and I) support greater transparency of physician billings. But this should include appropriate context for the public and be governed by an Act of Legislature as it is in other provinces. The real value in greater transparency is to show how much patient demand there is for services. Looking at a select 0.3% of physicians will not do this.

Ontario’s doctors are working with the government to fix our health care system, solve critical issues like hallway medicine and deliver the high-quality care our patients deserve. Part of this work is to recognize the value of services patients need and how those services are provided. We will continue to do this work with the government going forward.

Each and every billing submitted by a doctor means that one more patient has been treated and one less patient is waiting.