I Pray The Experts Are Wrong, Because Ontario Can’t Handle a Surge in Flu Cases

Note: this article initially was published in the Huffington Post in November of 2017, and is being reproduced on my personal blog site. The purpose is to outline that our system isn’t collapsing because of Covid. It’s collapsing because despite multiple warnings from people like myself that our system was NOT EVER prepared to handle an unexpected event. My thanks to Dr. Adam Stewart for reminding me I wrote this.

We know the hospital system has no surge capacity. If you are already at 110 per cent, where’s the room to surge?

This year, Australia has suffered through one of its worst flu seasons in history. There were 166,000 cases of the flu through September (their flu season lasts through October) which was up from 91,000 for all of 2016. Over 300 deaths were attributed to the flu in Australia this year, including many people who were apparently healthy.

Tragic as this was in Australia, is this a concern for Canada? Unfortunately, the answer is yes. While the influenza virus is famously described as “predictably unpredictable,” leading flu experts have noted that Australia (where the flu season typically starts first) is often a predictor of what happens in North America. It’s usually the same strain of influenza that crosses the ocean to our continent each year.

Now, there are something like a gazillion strains of influenza. I won’t bore you with molecular biology, but keep in mind that one particular family of the flu virus, H3N2, is a bad one. What’s worse, there are multiple sub-types of H3N2, which makes immunization a real challenge. You see, each year leading experts make the best possible guess at predicting which flu strain is going to affect the public and cater the flu shot to that strain. Last year, for example, they were spectacularly successful and we had a relatively mild season.

This year, Australia was hit by the H3N2 family, and while their vaccine DID have protection for H3N2, it still appeared to be a mismatch. Most likely this was because the H3N2 virus mutated and formed another sub-type that was not as effectively covered by the vaccine.

Which flu vaccine are we getting in Canada? The same one the Australians got. Which strain of flu seems to be coming to Canada? According to Health Canada, as of last week, the majority of detections are H3N2. So the experts who were expressing concern are unfortunately being proven correct.

The flu, of course, generally affects the elderly, the very young and the patients with chronic medical conditions (heart disease, kidney disease, cancer, etc.), or those with compromised immune systems (e.g. patients with diabetes). What’s worse, it weakens patients considerably and makes them prone to a secondary infection (usually a pneumonia on top of the flu) which may ultimately lead to their death or prolonged sickness.

The worry that Ontario physicians have with this situation is twofold. First and foremost, we are concerned for our patient’s well being. Despite many attempts to get EVERYONE vaccinated, the legion of anti-vaccination followers (led by leading virologist/immunologist/brain surgeon Jenny McCarthy) seems to have increased. Even a partially effective vaccine is better than none, and so it behooves everyone to get their shots.

Secondly, physicians already know that due to the woeful mismanagement of the Ontario health-care system by Premier Kathleen Wynne and her hapless Health Minister Eric Hoskins, Ontario hospitals simply don’t have the resources to cope with a surge of patients. This was proven in dramatic fashion this past summer when a shortage of beds in neonatal intensive care units played out. The short version is there was a strong need for an increased number of beds, and these beds weren’t planned for. Health Ministry spokesperson David Jensen tried to spin this in the media as a one-off event, referring to it as an “unusual surge.”

However, this is just ridiculous. All health systems NEED to plan for unexpected circumstances. That’s why best practice evidence shows that hospitals should, on average, run at 85 to 90 per cent occupancy. This allows planning for unexpected events (that are becoming more and more common).

Under Wynne and Hoskins’ watch, Ontario hospitals now routinely run at over 100 per cent capacity (many are between 110 to 120 per cent). This essentially means that if you have a 100-bed hospital, there will ALWAYS be between 10 to 20 people in the emergency room, lying on a stretcher, waiting for a bed in an inpatient unit. And that’s WITHOUT any unexpected surge.

What happens this year if the flu season is as bad as experts suggest it may be? Patients who are already weakened from other illnesses will, of course, go to the hospital to treat the dehydration, muscle aches, vomiting, secondary infections and so on that all come with the flu. But if they need to be admitted, where will they go? Will they wind up in “unconventional spaces?” (FYI: “unconventional spaces” are spots like storage rooms.) Is this what we can expect from our vaunted health-care system — to lie for days in a hallway with no dignity? We know the hospital system has no surge capacity. If you are already at 110 per cent, where’s the room to surge?

So, I ask everyone to do a couple of things. First, get your flu shot (some protection is better than none). Second, if you are unfortunate enough to need hospital care, please remember that the doctors and nurses in the emergency department are going all out with the resources they have (they just don’t have the space to provide adequate care). Third, if you are upset about your situation in the hospital, please contact Premier Kathleen Wynne (there’s an easy link here), and tell her what you think of her management of the health-care system. (We doctors have tried for the past three years, but she just doesn’t seem to want to listen to us.)

Here’s praying that the experts are wrong about this year.

What Role Should Nurse Practitioners Play in Health Care?

A recent look at some of the news stories around health care do not paint a pretty picture for Family Medicine. In Ottawa, a truly wonderful 41 year old Family Physician (whom I had the pleasure of meeting when I was OMA President) is closing her family practice due to burn out. The BC government is on the defensive over the shortage of Family Physicians. Medical School graduates are avoiding Family Medicine. The list goes depressingly on, but the point is clear.

Family Medicine is in crisis.

Jumping into this environment is former Ontario Deputy Health Minister Bob Bell and his colleagues. To fix Family Practice, they recommend expanded use of Nurse Practitioners (NPs), allowing them to work independently to replace much of what family doctors do. They claim that NPs can independently provide care for rosters of 800 patients, and collaborate with Family Doctors only for more complex patients. The authors reference a British Medical Journal (BMJ) study that suggests this will be “cost-saving.”

Bell doubles down on his beliefs that NPs can replace family doctors on Twitter by cherry picking data, in this case a Cochrane review:

One wonders if Bell and his colleagues bothered to read the reviews. If they had, they would have seen that the BMJ study on “cost-effectiveness” admitted:

“…it was not possible to draw conclusions about the cost-effectiveness of the complementary provider specialized ambulatory care role of nurse practitioners because of the generally low quality of evidence.

And that the “authoritative” (Bell’s words not mine) Cochrane review also stated:

We are uncertain of the effects of nurse‐led care on the costs of care because the certainty of this evidence was assessed as very low.

For those of you not versed in medical literature those phrases are the author’s way of saying they did studies where the results couldn’t be relied upon to be reproducible. Using these to promote a belief that allowing NPs to work independently to replace family docs is…….puzzling.

Bell’s belief that Family Docs are easily replaceable is nothing new. He planned on actually ending his career as a general practitioner. Apparently he thought he could easily slide back into it after having done it for a couple of years early in his career, then gone on be an orthopaedic surgeon for another few decades before getting involved in health administration and the MOH:

I don’t personally attribute any malice to his statement (though others on that thread did), I’m not sure that that Bell realized just how much he insulted every single GP in Canada with his seeming belief that he could simply suddenly switch gears after 4 decades of not being in primary care, and go back to being a GP without at least a residency. Hate to tell you this Dr. Bell, but Family Medicine has changed a LOT since you last practiced it. We have more than just beef or pork insulin for diabetes for example.

More to the point however, is there data out there that actually looks at the kind of system that Bell and his colleagues would propose? One where NPs scope of practice is drastically increased allowing them to work independently, and they replace the bulk of work that Family Doctors do? Turns out, there is.

In South Mississippi, the Hattiesburg Medical Clinic, an Accountable Care Organization that is very similar in structure to the proposed Ontario Health Teams (OHTs), did exactly what is Bell and his colleagues are proposing. Fifteen years ago, based on ongoing shortages in Family Physicians, NPs and Physician Assistants (collectively referred to as Advanced Practice Providers or APPs) were hired and allowed to work separately and independently with physician colleagues.

Did this work? In a word: Nope.

A comprehensive analysis of their findings (minimum of 11 years of data over a large patient population) was published in the Journal of the Mississippi State Medical Association. You can read the details for yourself but here are some highlights:

  • the cost for looking after patients who did not have end stage renal disease (i.e. were on dialysis) or were not in nursing homes was $43 a month higher per patient for those who were looked after by APPs than family docs
  • when the data was adjusted for complex patients, the cost of having an APP look after them, rather than a family doc was $119 per month higher (!)
  • these costs were attributed to ordering more tests/more referrals to specialists and MORE emergency department use (yes MORE)
  • Physicians performed better on 9 out of 10 quality metrics in the review

In short, doing what Bell and his colleagues are suggesting led to poorer overall health care outcomes at an increased cost.

Now to be completely clear, I personally have worked with NPs in a number of ways. I strongly believe they are an essential part of the health care team and provide a valuable service. In my practice, they have assisted me in providing care to my patients. When I had a couple of “cardiac kids” in my practice, I dealt exclusively with the NPs on the cardiology team at the Hospital for Sick Children (never once spoke to a Cardiologist or Cardiovascular Surgeon). When the Royal Victoria Hospital in Barrie had NPs on their oncology service, I discussed issues around cases with them exclusively. The NPs were at all times incredibly helpful to me and my patients. NPs definitely have a role to play.

I would also point out that the Hattiesburg Medical Clinic feels the same way. They strongly valued their NPs, and still have them on staff. But they have modified the way they provide care to ensure that all patients now have a Family Doctor but the visits to the clinic now alternate between the Doctor and the APP. On days when only an APP is in house, telemedicine back up by physicians is provided.

We need to build a better Family Practice system. In order to do so, NPs can and should play an essential role. That role however, is not taking on independent rosters of patients. It is working as valued members of a team that looks after a patient population, where each patient has a Family Doctor.

Patrick Brown is the Right Choice to Lead Conservatives

Most of my regular followers know that I am a long time Conservative. Heck, I was one of the Youth for Mulroney back in the early 1980s. Like all members of the Party, I’ve been saddened by the inability to win a national election since Stephen Harper lost in 2015. Canada would have been MUCH better off if he was Prime Minister during the Covid Pandemic. Playing to the media for photo-ops is one thing, but in times of crisis, we needed a leader with intellect, and Harper has that in spades.

Also like most members of the Party, I need to weigh who to vote for in the current leadership contest. Both the party and Canada are at a cross road. It’s not just a potential 10 years out of power. It’s about a current environment where unfortunately, Canada seems to have become a more divisive country.

Those of us who are on Social Media have seen it first hand (there is a reason looking at your Twitter feed is often referred to as “doom scrolling”). But there is also evidence of division elsewhere.

We see people who feel that they can assault store workers for enforcing mask mandates. Whether in Calgary, Peterborough, or elsewhere, this kind of behaviour speaks to a corroding of Canadian’s reputation as a kind people.

There’s also been a seeming uptick in racial violence in Canada. Whether it’s the rise in Islamaphobic attacks on Muslim women in Edmonton and elsewhere, or the increase in hate crimes against Canadians of Asian descent, or the continued inability to squash anti-semitism, or ongoing racism against our Indigenous people or more, Canada seems to be in a darker place than I can recall in my now half century in this country.

Against this backdrop, what we really need is a Prime Minister who can inspire all Canadians to believe that they belong to and are part of Canada. A Prime Minister who can at least be seen as someone who works to unite Canadians. A Prime Minister who truly believes that even if we have political differences, we all matter.

Instead, we’re stuck with Justin Trudeau.

A PM who preached feminism, but summarily dismissed two strong independent women for having the gall to disagree with him. As an aside, just how much better would our Covid19 response have been had Dr. Jane Philpott, now Dean of Queen’s University Faculty of Health Sciences, been in cabinet?

A PM who preached reconciliation with the Indigenous people, but still hasn’t delivered on clean drinking water on reserves. To show you just how much he thinks of the Indigenous, he decided to go on vacation during National Truth and Reconciliation Day.

And finally, yes, a PM who decided to deride and debase those who were involved in the “Freedom Convoy”. Yes, they went too far and should have gone home sooner (I’ve written that before). But the reality is that it was only a small minority of that convoy that were incorrigible racists. A real PM would have met with the group even though they disagreed with his views. It would have shown he listened to Canadians from all sides of the political spectrum. But instead, he chose to be a divisive force, instead of a unifying one.

Which brings me back to the Conservative leadership race. Conservatives face a choice not just of leaders, but of the type of party they want to build. Do we want a party that divides Canadians and marginalizes some groups but from the other end of the political spectrum? Basically a conservative version of Trudeau that will insult and deride those with progressive/liberal views.

Or do we want a truly inclusive conservative party? One that is open to all people. A party based on the principal of sound fiscal management and fair treatment for each and every single Canadian, regardless of background? Even if we have some differences of opinion on how to get there.

Of the current main candidates it strikes me that Pierre Poilievre is best suited to being an “attack dog”. No shame in that, every party needs one. Remember Sheila Copps for the Liberals back in the day? (Google her young ones). But being a good attack dog doesn’t mean you can lead a country.

Leslyn Lewis is clearly a brilliant lawyer but too inexperienced to be PM.

Jean Charest would be a fine leader and I would vote for him if he won. But the reality is that despite being from Quebec, where the party needs to win seats, he carries a lot of baggage as a career politician. This can hamper an election campaign.

This is why to my mind, Patrick Brown is the best choice for leader. He has worked hard to build relationships with many different communities in Canada. He is mayor of an incredibly diverse city (Brampton) and reached out many different minority groups. He’s realized that in order to build a better Canada, one must be able to sell a conservative vision to minority groups that historically have voted Liberal.

The best way to do that is to talk to them and engage them (which he’s done). And in so doing, surprise, surprise, find out that many of these groups value hard work, fair (but not excess) taxes, and fiscal responsibility, i.e. bread and butter conservative values.

For the sake of all Canadians and our children, the Conservatives need to win the next general election. The best way to do that is with a leader who understands the changing demographics of Canada, but also understands that at heart, Canadians are fiscally responsible, kind, and believe everyone matters. That leader is Patrick Brown.

I urge you to joint the Patrick Brown campaign by clicking below.

Why I’m Going to Vote “Yes” to the PPSA

Recently, the Ontario Medical Association (OMA) announced a Proposed Physicians Services Agreement (PPSA) with the MOH. The agreement is a year overdue, one of many delays caused by the Coronavirus Pandemic. It outlines a 3 year framework (retroactive to April 1, 2021) for funding patient services that are provided by physicians.

Like every single agreement between physicians and government in my almost 30 year career, it is basically something out of a Clint Eastwood movie.

The Good:

Increasing the number of family physicians who can be in a captitated model (salary + performance benefits). Increasing/improving the number of Alternate Funding Plans for specialists. Increasing/improving the number of Hospital On Call plans. Continue support for Malpractice Insurance. No Hard Cap. Improved parental benefits. A few others.

The Bad:

Some “aspirational” targets that seek to control physicians offices (particularly family physicians). I have absolutely no doubt that these “aspirational” goals will be mandatory goals in the governments opening position for the next round of negotiations. Just look at the governments position for Arbitration the last time around. The current aspirational goals will seem eerily familiar to those who have been following negotiations in detail.

Additionally, there seem to be a whole lot of fairly ambitious goals laid out to try and develop new processes, and redistribute funds at very aggressive timelines. It’s debatable to my mind whether these timelines will be met. (To be clear it is ALWAYS the Ministry team that is unable to meet the time lines, the OMA staff gets things done in time).

The Ugly:

One per cent increase per year?? In a time when inflation is 5.7%??

I suggest physicians access the contract and reading materials the OMA staff has put together. The staff have done an excellent job explaining the agreement and putting together a list of FAQs for you to review.

Additionally, if you are interested in more of a “big picture” approach about how to review the agreement as a complete package, my friend Paul Hacker has put together a truly excellent, easy to read, and for him quite short, document here.

I’m not going to write about any of that stuff. Rather, I’m going to write about the process to reach the agreement, and why after considering that, I personally am going to vote in favour. However, I do reserve the right to pinch my nose while doing so.

The negotiation process between physicians and government is laid out in the Binding Arbitration Framework (BAF). The short version is that it requires the government and OMA to start negotiating at least six months before a current agreement expires. It also sets guidelines for minimum time limits for how long negotiations can go on before moving to the next stage (e.g. mediation and arbitration). This time round of course, none of those timelines could be met because of the Covid Pandemic. Everything got pushed back (by mutual consent of both parties).

What is it about the process this time round that makes me want to support the PPSA? Let’s face it, nobody out there, myself included, is calling this a great agreement. So why support it?

Firstly, the government once again opened negotiations with a pretty lowball offer. Not sure how much I can say about the confidential negotiations process, but given the OMA negotiations team has already indicated there was a wide gap to start, and given we didn’t reach an agreement until invoking mediation, well, let’s just say there was a pretty big difference between the two sides to start.

Second, the Mediator (Mr. William Kaplan) is also the Arbitrator if we turn down the agreement, and head to Arbitration. I know, I know, the BAF states that there has to be an Arbitration “panel.” But the reality is the panel has a government appointee (Kevin Smith) and an OMA appointee (Ron Pink) and lastly Kaplan himself. I think it’s obvious who would make the final decision in such a circumstance.

In the 2018 negotiations, the government and OMA were unable to agree to an acceptable deal even through mediation. So we had no choice but to go for Arbitration. On this occasion, while many will argue that the OMA should have held out for more, the reality is that the OMA’s team also spent a lot of time with Kaplan. Got a sense of what he’s thinking, and what he’s looking at.

There’s no guarantee of what he would do in Arbitration of course. I’ve met Kaplan. I think I’d have more luck interpreting the emotions of a stone wall than him. He’s a tough guy to read. That’s probably an important skill to have when you are a mediator/arbitrator. But the OMAs negotiations team is really good at “reading the room” based on decisions Kaplan has made (e.g. extending the timelines and so on) during this process.

The choice then, to my mind, is pretty simple. We can vote for this agreement, as unpalatable as it may seem to many, and get on with implementing some of the benefits. Live to fight another day.

Or we can reject the PPSA. Which means we go to Arbitration. At which point both sides will likely revert to their opening positions in negotiations. Thing is, we already, by virtue of the having a mediated PPSA, have some insight into what the Arbitrator is thinking. To my mind, rejecting this agreement will simply kick things down the road six months (or more) at which point we will not get anything better.

My personal feeling is it’s time to move on. I’m going to vote in favour. I encourage all of you to read the briefs from the staff, and make your own decision.

Covid is Not Over – and It Won’t EVER Be

As provinces across Canada begin to lift restrictions from the Covid pandemic, there is a plethora of opinions raging about this. Some physicians feel the restrictions are being lifted too slowly. Others feel that it is just right. In Ontario at least, the most outspoken group are the physicians who demand ongoing restrictions. They have taken to using #Covidisnotover on Twitter.

Obviously, when dealing with a once in a century pandemic that has truly decimated patients and health care workers alike, there are still going to be unknowns going forward. But personally speaking, I think we have to realize a couple of things. First, Covid is not over. Second, and most importantly, it never will be.

Is the flu over? Is HIV over? Heck, are measles and RSV over? The answer to all of those is no. The viruses are still around, they are still infecting people and are mutating all the time (that’s why we need an annual flu shot).

There are always a certain amount of these viruses in the ecosystem. Why would Covid be any different? We are not going to completely eradicate Covid.

Given this – the question becomes, what do we do as a society?

One option, and certainly one that is promoted by the #covidisnotover types, is to continue ongoing restrictions, for much longer. Be it mask mandates, enforced vaccine passports, or continued limits on indoor capacity, the message from them seems to be to keep imposing restrictions for……well, I couldn’t really find consensus on an end date.

The most common argument for continuing restrictions (in Ontario anyway) is the continued positive case load. There are more positive cases than ever before, so why should we stop restrictions now?

Well, the short version is that while it is absolutely true that our case load is higher now than in, say October of 2020, many other factors have changed. In October of 2020, there were no vaccines. There were no oral medications that could help treat those who were infected. Guidance on the fact that Covid is airborne was still (shockingly) lacking.

In comparison, in March of 2022 over 90% of the adult population of Ontario has two covid vaccines, and are well on the way to their third. Evidence is clear that the vaccines are remarkably effective at preventing serious complications of Covid. There is now a strong emphasis on good ventilation as a way to reduce the Covid burden. The government is providing funding for Hepa filters in schools and child care settings. A protocol for rolling out the new oral medications exists, and, like all things, supply of the medications will increase with time.

So to compare just case numbers from October 2020 to March 2022, quite frankly is just comparing apples to oranges. We need to take all these other factors into account.

The other common argument is essentially “Look at Denmark!“. Pro restriction types point to the fact that Denmark lifted all Covid restrictions on February 1st, 2022, and now seems to have an exploding number of cases and mortality. Graphs like the one below are designed to shock people into thinking there is a catastrophe in Denmark:

But the graph doesn’t tell the whole story, and in fact a much more nuanced approach requiring a deep dive into the data is needed. I was going to try but I can’t do a better job of it than Michael Petersen did in his twitter thread:

The short version is that because so many people have Covid now, we need to do a better job of determining who died because of a covid infection (usually a covid pneumonia) vs who died of other causes, but incidentally happened to have Covid at the same time. A better graph showing the Denmark situation (taken from Petersen’s thread) taking this into account is here:

Before people start jumping all over this, let me also point out that I am acutely aware that there is a significant spike in deaths in Denmark recently, even if not specifically caused by Covid. We clearly need to do a deeper dive into why there were excess deaths. But part of that deeper dive must include whether deaths were caused by the restrictions themselves (delayed care, depression and mental health issues leading to people just giving up etc). In essence, is the cure (restrictions) causing more harm than the disease (Covid)?

Look, lockdowns and restrictions were initially necessary. There is good evidence that they helped to blunt the course of Covid. But there is also evidence that they have harmed society as well. The economic impacts with record government deficits that will tax our great grand children are well known. However, there are also other health care impacts.

In Ontario, we have a back log of 20 million health care services, leaving many patients feeling forgotten. There are consequences to delayed care and I have seen that in my own practice, and expect to see much more in the coming year. Yes, those consequences sadly will include deaths.

All of this is before we even consider the collateral damage done to mental health especially in our pediatric population. As Dr. Jetelina points out in her excellent sub stack, there has been a world wide increase in paediatric mental health issues. A 24-31% rise in children presenting with mental health issues and a shocking 69-133% (depending on age group) increase in children presenting with suicidal thoughts to Emergency Departments.

What does all this mean?

My personal feeling is that while we cannot ignore Covid (it’s a bad disease) and we need to continue to encourage vaccinations (they work), we need to start looking at the health care system as a whole. Should we mask in high risk areas? Sure. But should we continue to isolate people socially and restrict interactions in a lower risk population, when that clearly causes other harms? I would argue no.

We have been making decisions for a long time based on Covid numbers alone. There are other illnesses and disease that are out there, many of which have been worsened by the restrictions Covid has forced on us. We need to start basing our health care decisions on what’s best for overall population health, not just Covid.

Crisis at Trillium Health Partners Demands an Intervention

Over 20 years ago, I and a number of other physicians were involved in a significant dispute with our local hospital administration. The specifics don’t really matter now (it’s ancient history). But in general terms physicians like myself felt strongly that we were fighting for patient care against an administration that didn’t value our input or opinion. Administration at the time undoubtedly felt differently. Eventually, both sides became entrenched and the Ministry of Health had to send in a team to sort this out, after we went public with our concerns. The MOH bureaucrat even fashioned a new phrase, referring to their team as “Interveners”.

All of which is to say I still get nightmares when I hear of in house disputes at a hospital being made public, most recently at Trillium Health Partners in Mississauga. Not working at that hospital, all I can go on is what CTV News reported. 40 physicians at Trillium Health Partners have hired a lawyer alleging:

  • physicians “are targets of an abusive and unprofessional behaviour of the hospital administration.”
  • “terrified for their livelihoods”
  • “fearful to go work”
  • a physician was called “crazy”
  • “a toxic culture rooted in harassment, intimidation and threats”
  • an environment where “physicians are afraid to practice medicine”

All of this certainly brought back my own PTSD at the events that led myself and my colleagues to take action over two decades ago.

As mentioned, I don’t know the specifics there. But I can say a few things in general from not only my previous experience, but from other institutions where I’m aware of doctors speaking out.

First, doctors in general hate speaking to the media and going public about internal conflicts. It’s one thing to talk about medical issues that pertain to the health care needs of the population as a whole. But to go out and air dirty laundry? It’s not in their nature. For something to reach this point, it usually means that every possible avenue has been exhausted, and there is a real concern for patient care.

Second, every hospital has multiple processes for addressing concerns. There’s a Medical (or Professional) Staff Association that advocates for the needs of their professional staff. There are numerous committee structures and depending on the concern the issues can be brought there. There are internal complaints processes and various Human Resource department protocols. There are chiefs of departments whose role includes addressing concerns fairly. Basically a lot of ways to bring problems to the attention of the higher ups.

Third, doctors in general put up with a lot of bureaucratic non-sense just so they can get the job of looking after patients done. Whether it’s ludicrously difficult hospital IT systems, policies that require us to duplicate our efforts, or any number of roadblocks, physicians complain privately about the working environment, but put up with it because we want patients well looked after.

In that context – to see physicians do what they’ve done, and write to the Minister demanding she appoint a supervisor (essentially someone to take over the administration of the hospital) signals a complete failure of all of the internal processes, and a dramatic escalation. This only happens when the two sides are entrenched.

What next?

What’s Likely to Happen:

Usually, administrations in such a situation tend to circle the wagons and go on the defensive. Attempts are made to minimize the concerns or denigrate the physicians as a small group not representative of the whole. Evidence is produced suggesting the concerns were appropriately reviewed and dealt with.

As an aside, Trillium has already done this by having their own lawyer investigate the complaints and, surprise surprise, the lawyer Trillium pays found Trillium did nothing wrong. I would have thought for issues of this magnitude it would be appropriate to bring in an external person to review. Maybe Trillium didn’t do anything wrong. But surely having an external person say that would carry more weight.

Then, if physicians make enough noise, the issues continue to percolate, the general public expresses concern and politicians get scared. In our area, the issue became so toxic that enough physicians decided to resign their privileges and our Emergency Department was in danger of shutting down part time.

After months of agony, somebody at the MOH (plus/minus political intervention) realizes they have to do something and appoints a third party with the power to actually do something and make some necessary changes.

What Should Happen:

Why go through additional months of grief? There’s clearly a crisis there. The residents of the catchment area of the hospital must surely have concerns about the care they will receive when they read the articles from CTV News. Having doctors who are fearful of the working environment simply cannot contribute to good patient care.

The MOH appointed their “Intervener” in my hospital and the Intervener had the power to tell both Administration and Physicians when they were offside. I personally got told I was going too far offside by him during the process, and I know Admin was also told they had to back down on some things. At least he was fair.

I don’t know who’s right and who’s wrong at Trillium, but patients at Trillium need to know that something is being done to address these concerns and ensure there is safe environment for the caregivers. To that end, the MOH needs to appoint an independent third party to help the situation sooner, rather than later.

For a link to CTV News’ follow up report on the issues that includes comments from yours truly, click here.

Governments Should Listen to the Experts and Ease Covid Restrictions

It’s time.

For the past two years, the majority of Canadians have done their part to help combat the greatest health care crisis in a generation. We’ve dutifully worn masks, social distanced, gotten vaccinated and done our part to help protect others.

When the pandemic began (has it been two years already?), very little was known about Covid19 and still less was known about how to treat it. Public Health leaders did their best to provide guidance in an ever changing environment. They got some stuff wrong (remember how we were all initially told not to wear masks ?). But they got more stuff right (the lockdowns did help slow the spread of Covid19).

We all paid a terrible price to fight Covid. Job losses. Economic uncertainty. Decreased social interaction. Mental health impacts on ourselves and most troublingly our children. Delayed medical procedures. The list could go on forever.

Through it all however, was the hope that at some point the pandemic would either end, or change to a more manageable form and we could start to live more normal, if not completely normal lives. I submit that time has come.

In Ontario, we have almost 90% of residents over age 12 who have had two covid vaccines. This would be the number we were told was necessary to achieve herd immunity. I understand that most people need three shots. But the reality is that with Covid being a seasonal virus that seems to mutate regularly, we may need annual booster shots. Surely we won’t keep restrictions forever because we will likely need vaccines forever.

Additionally, we now have new promising medications to treat covid infections. An oral medication that is 90% effective in reducing hospitalizations has been approved by Health Canada, and early distribution to those at highest risk has already begun. I appreciate we need to ramp up production of the medication, and have more of it in stock, but at least we have viable treatment options.

It’s not just this old country doctor saying we need to ease restrictions more. Last week, Ontario’s Chief Medical officer of health himself stated that we needed to re-assess the proof of vaccination process. Canada’s Chief Public Health Officer, Dr. Theresa Tam admitted that we needed to get back to some normalcy. Despite the fact that British Columbia had some of the highest Covid related death tolls with the Omicron wave, even their provincial Health Officer, the excellent Dr. Bonnie Henry, signalled that restrictions would be easing.

I would note that throughout the pandemic, there have been calls for all of us to “listen to the experts” and follow their guidance. Well, they are all signalling that it’s time to change the approach and that it’s time to start lifting restrictions.

To be clear, the restrictions should not be lifted all at once. There should be a stepwise approach to lifting them, but that stepwise approach should be relatively rapid now.

The first thing to go should be the Vaccine Passports/Mandates. Before I go further let me be abundantly clear – I strongly urge everyone to get vaccinated (unless you are one of the one in 100,000 people who has a legitimate medical reason not to). The covid vaccines were incredibly effective against the alpha to delta variants of Covid. They are “just” really good against Omicron. However, with even Dr. Moore admitting that the vaccines will not stop transmission of the Omicron variant (but will drastically reduce your risk of getting critically ill from it) the passports/mandates make no sense anymore.

As an aside, my loyal readers (both of them) will remember that I wrote on July 30, 2021 that vaccine mandates were a bad idea and would “embolden hesitancy and create more fear and mistrust.” Look what’s happened. We now have our nation’s capital essentially under siege from a convoy of people who have been further emboldened by these coercive measures. Think there is enough trust there to come to an amicable solution? Particularly in light of Dr. Moore’s comments that transmissibility will not change if vaccinated?

This is in no way meant to support whatever the Ottawa convoy/protest/blockade is calling itself right now. They have frankly lost the moral high ground by not calling out the fringe few among them who are anti-semites, racists and just plain loons. They need to leave Ottawa and go home.

None of that, however, changes the fact that since you can get Omicron from a vaccinated person as well as from an unvaccinated person – there is no point to a vaccine passport. Get rid of it now.

Once that’s done, the next step should be to ensure our health care system goes back to full regular work and then some. We are already severely backlogged, and there is a whole lot of overtime needed to catch up on the delayed medical procedures.

Next (and in short order) capacity needs to be increased at restaurants/arenas/other indoor gatherings. We need to allow many of the businesses who have suffered terribly to start getting back on their feet.

The last step should be to remove mask mandates. Covid is airborne, and as such, masks provide a significant amount of protection. It will likely be a bit longer yet before we can say that Covid 19 is endemic (always circulating in the community at a stable level without fluctuating) as opposed to pandemic (essentially prevalent at a higher level with significant impacts on the health care system). So mask rules should be the last to go.

But make no mistake, the harms of all the other restrictive measures, whether on significantly delayed health care procedures, or enormous effects on government budgets and the economy now clearly outweigh the effects of continued restrictions.

It’s time to start lifting.

For those of you interested in such things I briefly spoke about Covid19 on CTV News and the link is below where I did mention vaccine passports had to go.

CMAJ Disgraces Itself By Publishing Islamophobic Drivel

You know, I really wonder if physicians organizations that claim to “support their members” really understand what that phrase means. Time and time again we’ve seen physicians representative groups fail their members. Now we have the Canadian Medical Association Journal (CMAJ) allow an attack on muslim members published.

I’m talking about the CMAJ decision to publish a letter by Dr. Emil that states categorically that the hijab (a VOLUNTARY head covering worn by some muslim women) is an instrument of oppression:

Seriously, the Journal of the Canadian Medical Association, an organization that proudly claims to want to promote diversity and inclusion, that boldly states “diversity is our strength” and has developed background papers in diversity to promote it’s agenda, thought it was a good idea to publish a letter that:

  • claims the hijab is an instrument of oppression
  • conflates the hijab with institutionalized child rape (!)
  • claims that a hijab wearing women wouldn’t be allowed to ride a bike (!!)

The whole letter is simply a series of islamophobic tropes that one would expect to find in alt-right white supremacist type websites. The fact that it was the editor of CMAJ who wrote the headline, only adds to the pain and hurt caused by this whole episode, despite the fact she has since apologized.

I’m forced to wonder, what would have happened if I commented on, say, Orthodox Jewish women, many of who choose to wear wigs to cover their hair? I obviously don’t know the exact religious reasons why but a friend of mine pointed out this link on chabad.org that goes into it in more detail. Now supposing I had written a letter saying that an Orthodox Jewish woman making herself “unavailable by covering her hair” was akin to misogyny/oppression/child abuse etc etc.

Had I said that, I frankly would expect everyone to call me an anti-Semite. And had I written that to a medical journal, I would never expect such a letter to see print.

And that’s the real problem. It shows a double standard that exists within the CMAJ. I would never be able to get a letter full of negative connotations about Jewish/Indigenous/Black/LGBTQS2+/insert minority of choice published in the CMAJ. They would rightfully feel that publishing that would harm a segment of their members and would not be productive to building an inclusive organization.

But a letter (and headline) that blatantly expresses anti-Muslim rhetoric? Apparently that’s ok.

To be clear, this is not really an argument about free speech either. Dr. Emil has a right to his view as distasteful as I find them. He’s free to spout this nonsense whenever he wants and I’m free to think less of him every time he does. Those are our rights as protected by the Canadian Charter.

But, when the journal of a representative organization allows publication of a letter that attacks a segment of their membership, the type of letter that they never would allow if it targeted another segment, well, we have a problem.

Many muslims have been left reeling these past few years by a series of events. An eleven year old girl attacked for wearing a hijab. A pregnant muslim woman attacked by teens who try to rip off her hijab. A spate of attacks against hijab wearing muslim women in Edmonton. The tragic killing of a muslim family in London, in a truck attack where the perpetrator was able to identify the family as muslim (likely because the women were wearing hijabs).

There are many more but you get the point. Hijab wearing muslim women are being attacked repeatedly. As an aside this only increases the tremendous respect I have for those who choose to wear a hijab. To have such strength of faith that you would still wear a hijab, knowing that you might be targeted for an attack, shows courage, resilience and a resolve I find inspiring.

Now, a mere 11 days after a school teacher is removed from her class for wearing a hijab, we have the CMAJ, a journal of an organization that allegedly represents close to 80,000 doctors, refer to that same hijab as “an instrument of oppression.” Seriously, has not anyone at CMAJ ever heard of the phrase “victim-blaming??”

I was going to tell you what I thought, but Danyal Ladha said it much better than I could on twitter:

Having caused such harm, the ball frankly is in CMAJ’s and the CMA’s court. Will they retract the article, issue a full and complete apology, and reach out to groups like the Muslim Medical Association of Canada to learn and educate themselves about how their actions have caused real pain to their members? Or does the vaunted push for diversity and inclusion the CMA is promoting not apply when it comes to muslims?

Time will tell.

It’s Time to Open Up Nursing Home Capacity

Recently, I posted what I referred to as a controversial tweet about the need to open up nursing home beds that had been closed during the seemingly never ending Covid pandemic.

While there was not much “controversy” in twitter feed as a result of this, it did lead to some questions being asked during an interview I gave for CTV News.

While I certainly appreciate the professional nature of the reporter (the always adept Kraig Krause), the reality is that 30 second blurb on this topic, in an interview about all things COVID, can’t really do it justice. So let’s delve into this deeper.

It’s no secret that Ontario’s Nursing Homes were hit hard by the Covid pandemic. One nursing home in my region, Roberta Place in Barrie, was ravaged badly by the disease. I still grieve for all of the residents and families there, including those who survived as they likely continue to suffer some of the after effects of what transpired.

In the wake of these and other such stories, the Ontario government quite correctly limited the number of residents in ward beds at nursing homes. Many of Ontario’s nursing homes are very old buildings. The nursing home I’m honoured to be a medical director for has great ownership (private as it happens) and great staff, but the building itself if 52 years old and would not meet newer, more modern standards for nursing homes.

When my nursing home was built, having a ward bed (four residents to a room) was thought to be reasonable. Given that Covid is airborne (like most other respiratory illnesses!) the COVID19 Directive #3 (linked above) for nursing homes limited the number of residents to two per room. This made perfect medical sense at the time, and I certainly supported it then.

The reality however, is that health care is not limited to a single disease. We do have Covid of course, but we have a whole lot of other illnesses that we need to deal with. The Ontario Medical Association has estimated that a minimum of 16 million visits or procedures have been delayed as a result of the pandemic. We can’t keep delaying these. We need to address all the other health care issues that Ontarian’s have, and not just maintain sole focus on Covid.

Right now, I personally have two patients who are in hospital waiting for a nursing home bed. They are not acutely ill. They do not need aggressive medical treatment. They need a nursing home. But they can’t get one because of the massive shortage of nursing home beds. And while I strongly applaud the government for planning to build more beds, they won’t be here for 4-5 years.

At the nursing home I work at, normally 60 patients could be housed, but it’s now limited to 45 because of the rules implemented during the pandemic. I imagine it’s one of many nursing homes that has been limited. While opening up those closed beds (at all the homes) likely won’t be enough, it will help alleviate the stress on hospitals. This is particularly important given (as I write this) no one knows how bad the on coming Omicron wave will be.

But wait – are we not risking increased covid infections in the nursing homes by doing this? We would be increasing, for lack of a better phrase, population density in these homes. The answer is not as straightforward as one would think.

First we now know that three doses of the Covid19 vaccine provides the maximum amount of protection. Just about every resident of a nursing home has had three doses – as have staff. There will never, ever, ever be a vaccine (for any disease) that is 100% effective. But that fact that our most vulnerable patients have had three doses is incredibly reassuring.

Second, we would have to ensure that nursing homes have the funds to put in proper air purifiers (with Hepa Filters) in their facilities. I’m not asking for a complete re-vamp of the HVAC systems (that will take too long). But even small portable air purifiers will make a difference.

Third, we would need to ensure a rapid swab and immunization policy for staff and visitors of nursing homes to further reduce the risk of Covid entering a facility. Just tossing it out there but how about all staff get swabbed once a week regardless of vaccine status, and visitors twice a week?

Fourth, as one of the smartest people I know put it, a bed is just a piece of furniture. We have to ensure that the homes who are short on staff, now have the ability to hire extra staff to take care of the residents in these beds.

The health care system is a behemoth. It is also interdependent on all of its various parts working together. A shortage of nursing home beds, means more people in hospital waiting for nursing homes, which reduces the hospitals ability to provide acute care which leads to further backlogs and delays in medically necessary treatments.

We cannot make nursing homes 100% safe (we can’t make anything 100% safe). But re-opening currently closed nursing home beds in the safest possible manner, will be a small step in the right direction. It will also provide the hospitals with a little bit of extra capacity, should Omicron stress the system more.

Corporatization of Medicine Continues Unabated

Last week, a story came across my feed that seems to have been almost completely ignored by most who are in/or follow medicine and health systems. WELL Health technologies announced that it has purchased 100% of CognisantMD, the developers of the Ocean platform. For those who don’t know, Ocean is a platform that links to various EMRs and allows for securely emailing patients, eReferrals, filling out forms online, and a bunch of other features.

Full disclosure, my practice uses Ocean as well (for now). Personally I find it somewhat clunky and not as smooth as advertised, but there are some positive features to it.

What’s the problem then? It’s a friendly corporate takeover. Happens all the time in the business world.

To understand the concerns, let’s look at what WELL Health does. According to their own website, WELL Health offers a wide array of digital health care solutions. But they also state they are “Canada’s largest outpatient medical clinic owner-operator and leading multi-disciplinary telehealth service provider”. In essence, they run the clinics, and physicians work for them.

A further dive into their strategy, under the “Reinvest” tab states:

“Acquisition of cash generating companies leads to increased cash flows which are re-invested to make additional new cash generating acquisitions.”

Pure and simple – WELL Health is a private, for profit corporation. There is of course, nothing wrong with private corporations. Most people who follow my twitter feed know that I am generally pro-business, and on most issues land on the right side of the political spectrum. I firmly believe we need more, not less, businesses in this country and we need to make it easier for businesses to function.

BUT – acquisitions like these, and the continued take over of clinics by corporations should make us ask legitimate questions about protection of individual health care data. It is no secret that the reasons that companies like Google and Facebook have become so successful is that they found a way to monetize personal data. In much the same way, personal health care data has enormous economic value to companies. Whoever can find a way to properly monetize this, will be the next Jeff Bezos/Mark Zuckerberg and so it’s no wonder that companies are extremely interested in getting into this field.

As I mentioned in a previous blog, Shoppers Drug Mart, for example, recently acquired a stake in Maple, a leading virtual care only provider for $75 million. They continue to advertise on their website (as of Dec 6, 2021) the ability to diagnose strep throat virtually (which personally I find questionable) and then to send antibiotics to a pharmacy near you (I’m guessing there is going to be a Shoppers Drug Mart near you).

Screen shot as of Dec 6, 2021

In a circumstance where a patient contacts Maple, the doctor or NP gets paid to virtually assess a patient, Maple gets a percentage of the fee to cover overhead – which presumably will be reflected in shareholder value to Shoppers. If a prescription gets sent to a Shoppers, well, they make a profit there too. Neat business model.

But it’s not just companies that already have an interest in providing health care related services that are trying to get involved in this field. Amazon is jumping into health care with a telemedicine initiative. Google has long planned to get into health care, and while not terribly successful yet, I doubt they will stop trying. Heck even Uber (!) wants to get involved in health care.

It’s easy to see why everyone wants in. There is a lot of money and potential profit in health care. And while I am all for companies making a profit, that doesn’t mean that we can’t ask some hard questions about the protection of personal health care data such as:

  • How secure is the data that is being held in the servers owned by these corporations?
  • How do we ensure personal health data doesn’t go where it’s not authorized? (eg. supposing the parent company owned a family practice clinic AND an disability insurance company)
  • How do we ensure personal health data is not to be used to monetize other aspects of a business (eg. supposing a walk-in clinic was owned by a pharmacy. A patient attends there for a renewal of cholesterol medications, and then gets ads offering, say, flax seed oil capsules that are helpfully sold by that same pharmacy).
  • How do we ensure aggregate health data housed in those servers is only used to help the community at large (eg. finding communities that may need extra resources for, say opiod addiction).
  • If a physician stops working at a clinic owned by MegaCorp Inc. for whatever reason, how does that physician access their charts after the fact (I’m aware of a number of cases where access to patient records were cut off immediately upon the physician leaving such a clinic).

I’ve just posited a few questions. I’m sure there are many more. I believe that most Canadians strongly value health care privacy. As more and more businesses attempt to get involved in health care delivery, it is vital that we have a framework for oversight that ensures that patients have the absolute right to protect their personal health information. Sadly, I don’t see any organization/government agency out there asking these important questions.