Dr. Silvy Mathew guest blogs for me today. She is hands down one of the smartest people I know. She writes about her experience in visiting the ER to help a family member. Dr. Mathew has been a strong advocate for health system reform and it is a loss for all Ontario residents that her warnings about the impending crisis in health care were not heeded by Health Ministers dating back to Eric Hoskins.
A few days ago I was in the Emergency Room (ER) with a family member. The ER was slammed. The paramedics were lovely and about four teams that I could see were stuck in waiting room, waiting for their patients to be triaged. We were on a stretcher by the front sliding doors. Almost outside.
We were there for urgent imaging, and possibly consultation. We tried to do this in the outpatient setting, but lack of access to both urgent images and consults for urgent care makes that impossible. So we go off to ER by EMS (needed for transport).
I’m fortunate. I am able to fill in gaps. I can advise triage what issue is, as they can’t do physical exam in the waiting room in front of what seems like hundreds of people. I can provide medical information on relevant questions. I can monitor the patient status for changes.
I did remind staff after several hours to check blood sugar as my relative is an insulin dependent diabetic, now off food/fluids. I did remind about necessary medications to be given. Of course, if I wasn’t there, they may have reviewed the chart closer but they were clearly slammed and trying to manage.
And we weren’t in distress. My family member was unable to advocate for themselves. We got imaging about six hours in, and I watched the imaging staff, working with 50% less nursing staff, literally just running in and out moving people. Doing their best.
We had excellent care from people busting their butts. But so many potential falls through the cracks and errors. Twelve hours later, we got home, luckily without any new issues from ER. And we had a plan. And we had a specialist who called first thing in the a.m. to ensure we have close follow-up.
The system in Ontario has relied for decades on individuals and work-arounds making things work (like above) when the system design is archaic. Successive Ontario governments have refused to participate in strategic multi-pronged co-design, instead of piecemeal band-aids.
I have worked for 15 yrs in Ontario health care. I’ve witnessed how far things have fallen and how none of our work arounds previously used are available now after the Covid 19 pandemic, for multiple reasons. I’ve participated with the Ontario Medical Association and sat on bilateral committees with the government to try to advocate for system change.
I’ve witnessed how siloed and unaware most people outside of primary care are. Family Medicine is the canary NOT the Emergency Department. The issues that have caused this system collapse have been occurring since 2012. Many of us, especially Dr. Nadia Alam, tried to be loud and warn.
Last year, in 2021, we gave up. It was obvious to us it was too late. We heard for years from our mid-career colleagues about how they couldn’t do this anymore. How they wouldn’t work in a system that didn’t allow them ANY joy or success while taking more and more from them personally.
Covid-19 just pushed the dial a bit faster. The family doctors who were hanging on from retiring have chosen to live now (not leave, but LIVE). The mid-career family docs are struggling as mentioned above and also choosing to leave family medicine if possible, because nothing is working in it. Obviously, new graduates are terrified.
And so here we are, and the CCFP answer to this is to ADD a third year to residency. Because somehow they think adding more school, asking people to take on more debt, delay starting their lives longer, while having less non-academic preceptor support will somehow help?
What it will do is: add even more fuel to the family medicine crisis and shortage. It’s not gonna teach you how to run a business (last I checked real life experience mattered more). It’s not going to teach how to manage complexity in real life. It WILL drive more people out of family medicine residency.
What we REALLY need is a re design of the health system. You want people to do this job? LET them. You want family doctors to work at the top of their scope? ENABLE them. Support access to resources OUTSIDE of hospital and provide help to coordinate.
Stop advocating for more debt and school CCFP, and advocate for real life mentorship, group practices and shared care. You want Emergency Rooms to not house people? Fund home care and long term care. Fund resource teams to support those in seniors neighborhoods already. Use a community approach.
While we are at it, stop spending all the money on pharmacology. Fund allied health, encourage exercise programs and healthy meals because that’s WAY more useful than the hundreds of thousands of dollars of Botox we spend on contractures AFTER they occur. Keeping people mobile keeps them out of hospital and long term care.
The Canadian media can stop asking if health care has collapsed, anyone working in it knows it has. It will show in a year or two, when the numbers of late-diagnosed cancers, life expectancy and other markers of care get affected. But in real-time we are seeing it now.
If we don’t have some real leadership here and some true innovation, we are in for some truly sad times in the next decade. End.
justanoldcountrydoctor 
40 years of compounded declining investment in healthcare brought us to where we are at today. Doctors businesses represent a huge under-recognized part of our system, and these businesses have had a noose tightened on them with each successive subinflationary physician services agreement. With each agreement Doctors absorb more of the costs of our healthcare system in order to pay their staff and their overhead and manage their patients with hours of unpaid time since the implementation of electronic records.
With physician businesses as lean as they are, there is no room for innovation or adding to the team. Rural areas in particular cannot benefit from a healthy fee for service clinic they can offer many services out of that office if it were well enough funded. I went to my dentist last week and was amazed by the amount of staff employed. They had scribes along with the usual numbers of dental assistance, office staff and hygienists. Clearly over the last 40 years the physician’s office and the dentist’s have gone in vastly different directions.
In place of the successive cuts to our system, the government, along with the academic think-tank [which often work in a non fee-for-service environment] continue to try to invent changes that purport to replace the well capitalized physician office. Teams of allied healthcare providers that are not hired by the physician, nor their business, offer care to the patients of one physician business but not another. These are highly inefficient, clunky and expensive ways to augment the businesses of physicians. The administrative nightmare that physicians face daily in their own offices has become quite alienating..
While we all scramble and scratch our heads about how to reverse 40 years of income loss in a system that does not allow us to make up the lost investment in the gap fees that many physicians don’t charge for services, maybe it’s time to ponder and revolutionize these businesses by finding ways for them to close the gap by considering all of our options..
It is time for us to change the conversation about physician funding. Government could apparently afford to pay more, but it doesn’t want to. And the power dynamic is so engrained that even an arbitrator agrees that the government should always get what it wants cuts to physician services that are less than the rate of inflation with each agreement. With each agreement more of the healthcare delivered funded by physicians delivering the care – and their offices – and their healthcare teams.
To do this we first need to clearly identify the gap in physician fees. This will differ by specialty, and overhead is only part of the puzzle.
Then we need to explore ways for all physician businesses to close “the gap”.
Investment without strings allows for innovation. Innovation at the local level by physicians leading that part of the healthcare system is the way for us to slowly move back to a healthier healthcare system.
I think our patients will want us to grow our businesses and flourish. Let’s get some good data together about “the gap”, and then talk about what we can do to close the shortfall in investment in physicians and their offices.
thanks for your excellent article Silvy!
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