Moving Procedures to IHFs is a Step in the Right Direction

Let’s say you are a patient with high blood pressure in Ontario. It’s time for a check up. If you are lucky enough to have a family physician, you will go their office. Your family doctor will check your blood pressure and perform additional physical exams as necessary. If you are due for additional tests, they will order that and renew your medications. They will likely be paid fee code A007, currently set at $36.85. Out of that $36.85, your family doctor will put some aside to pay the staff, some for cleaning, some for rent, some for other expenses. The remainder, the “profit” if you will, your family doctor will keep for themselves.

Additionally, your family doctor will be required to keep their medical equipment in good order, vaccines in a fridge at consistent temperature, sterilize their equipment and so on. Medial charts must be kept legible and comprehensive. Your doctor will be subject to inspections from their governing body, the College of Physicians and Surgeons (CPSO) to ensure they comply with this.

None of this is new, and it’s how health care has worked in Ontario for decades.

It’s therefore amusing to me to see the righteous indignation on social media when the Ontario Government announced that it would allow more procedures to be done outside of hospital, in an attempt to start to catch up on a backlog of health care that some estimates place at 20 million procedures. The frenzied cries of how this is scheming to create two tier health care where you pay with your credit card have come from the usual suspects.

Premier Doug Ford and Health Minister Sylvia Jones announcing the expansion of Independent Health Facilities

Ontario has had Independent Health Facilities (IHFs) for decades. This is not a new concept. Just like your family doctors, these IHFs bill OHIP for services that are insured, and in return perform a procedure/test/examination on you the patient. They are subject to inspection by the CPSO (just like your family doctor) and have to stay up to standards.

As technology has evolved, many procedures that were once done only in hospital can now be done safely outside of hospitals. Cataract surgery for sure. Colonoscopies/Gastroscopies as well. Arthroscopies are safe and even some joint replacements can be done as outpatient surgery now.

And, just like a visit to your family doctor, you would go to the IHF, the physician would get paid for the work they do by OHIP, some of what they get paid would go to cover their overhead, and the remainder, the profit, they would keep for themselves.

Philosophically, there is NO difference between these two scenarios. So it is extremely curious that people are raising such a furious response to this. Essentially they are saying “it’s ok for family doctors to own their own clinic and keep a profit but it’s not okay for a specialist to do so.” Talk about two tier!

Now that’s not to say there aren’t some practical considerations that need to be thought out.

  1. Where will the support staff (particularly nurses) come from?
    • My feeling on this is that right now we do have a number of nurses who have left hospitals because of the stress of working there. They are never going back. If we build these outpatient surgical centres as part of the hospital bureaucracy, not only will it take longer (hospital bureacrats have never met a committee they didn’t like) but when the hospitals go to hire staff, they will likely want the staff to be able to work in other parts of the hospital and take call. The nurses who left the hospital will NEVER agree to that. Maybe some of these nurses would work in an IHF if they were guaranteed daytime hours. I don’t know how many. But it will be more that the zero that will go back to a hospital owned facility.
  2. Where will the surgeons come from?
    • Fun fact that you may not know. We do have a shortage of doctors. But we also have 150 unemployed orthopaedic surgeons in the province. I’m serious. And I agree with Canadian Medical Association Journal that this is a sign of poor planning. The real problem for most surgeons is lack of operating room time. Having IHFs with operating time will allow them to work and catch up on the health care back log.
  3. Will there be charges outside of OHIP?
    • The reality is that OHIP only covers some things. If you need a Drivers Medical for example, OHIP does not pay for that. Your family doctor will charge you. Same for sick notes, prescription renewals without a visit and more. Philosophically, there is again, no difference between what your family doctor would do, and IHF would do if you wanted something that OHIP didn’t cover (an upgraded cataract lens for example). My father paid for upgraded lenses when he had cataract surgery (in a hospital), and that was something like 15 years ago.
  4. How will we ensure appropriate care?
    • This is a biggie, and the one area that we really need more details on. One example, if I order an MRI of a spine on a patient, I have to fill out an “MRI Appropriateness Form”. This form ensures that clinically, the MRI is required and if the patient doesn’t meet the clinical criteria, the MRI is declined. This is process is only in place at some hospitals. We do need something similar in place if we are to have IHFs do MRIs and other tests.
  5. How do we ensure physician coverage at hospitals?
    • Another biggie. And another area where we really need some more details. What happens if someone has, say, a gall bladder is removed at an IHF and unfortunately the patient has complications? Obviously they will need to go to a hospital. Off the top of my head I would suggest that an IHF only get a licence to do surgical procedures if all of the surgeons have privileges at a nearby hospital so that they can manage their own complications. There may be other ways around this. But there clearly needs to be some work done here as well.

In short, Ontario is finally taking some steps that have the potential to reduce the overwhelming backlog of medical care that patients are experiencing. Instead of throwing up egregious “two tier American style health care tweets” based on ideology alone, we need to work on the practical details of this move to ensure that the roll out is done in the most effective manner possible. Even with that, it will still take years to make a meaningful dent in the backlog of health care.

But I can tell you that if we listen to what the politically motivated folks on Social Media want (have the hospitals run these facilities) it will instead, take decades.

Will Pharmacy Prescribing Improve Health Care?

Pharmacists do a great job as part of a health care team. In hospital and nursing homes, I get expert guidance on dosages of potentially dangerous medications. I am also fortunate to have community pharmacists on a secure electronic messaging platform to discuss issues around medication complications/interactions/dosages and so on for my patients.

But, will it improve health care to let them treat minor conditions?

I expressed my displeasure on Twitter about the recent move to allow pharmacists to treat certain minor ailments:

A few pharmacists were not amused. It was pointed out to me that Ontario is one of the last provinces to allow this, and that it has “worked well” in other provinces.

But what exactly is the definition of “working well”? Politicians love it, mostly because it allows them to say “see we are taking steps to make your life easier.” Patients love it because they can say, “Jee, I think I have a bladder infection, now I can just get the antibiotic when I want.” Of course patient satisfaction will be high.

Unfortunately, as I wrote about a few years ago in the Huffington Post, patient satisfaction does NOT correlate with good health care or outcomes. As counter intuitive as it may seem, higher patient satisfaction scores correlate with a 9% higher cost per patient AND a 12 percent higher hospital re admission rate. Patient satisfaction should not be used as a metric to determine any health care policy.

On Twitter, Nathan McCormick suggested that pharmacists have a lot to offer and linked to an article from New Brunswick on how it’s worked well there. Unfortunately (and I stand to be corrected) the article suggests the diagnosis of urinary tract infections was made without a urine culture, or even a urine dipstick test (which is less accurate but still something). So there’s no way to sort out how many people had a true bladder infection, or simply “felt” like they did, which happens. The article also puts a strong focus on patient satisfaction and convenience, which as mentioned above, is not the same as good health care.

Nardine Nakhla asked me to familiarize myself with an article she wrote about how Ontario developed the process. There’s a lot to like in what’s written there:

  • A recognition of overprescription of antibiotics as a world wide problem
  • a focus on ethical standards based behaviour by pharmacists
  • A minimum amount of training for pharmacists before treatment minor ailments
  • The requirement for pharmacists to contact the family doctor or nurse practitioner when treating a minor ailment

Once again this doesn’t really reflect true health care outcomes. It also references the aforementioned New Brunswick article and specifically stated there was high patient satisfaction there.

Let’s look at just one area of concern, antibiotic usage.  Global overprescription of antibiotics is a world wide concern.  It leads to increasing antibiotic resistance and the formation of new, drug resistant bacteria.  A look at Canadian data shows that there is intra provincial variation in the number of antibiotic prescriptions.  Newfoundland, where pharmacists have been treating minor ailments for years, has the highest rate of antibiotic prescriptions. British Columbia, where pharmacists are expecting an expansion of their scope this spring, had the lowest.  

From CMAJOpen: Interprovincial variation in antibiotic use in Canada, 2019: a retrospective cross-sectional study

World wide , of the ten countries with the most antibiotic use, Cyprus, Romania, and Greece allow them to be purchased directly from pharmacies. (I stuck to EU countries with more modern health systems for examples).

Kristen Watt wrote a piece in the medical post criticizing physicians for complaining about these new powers and asked me on Twitter to provide evidence from other locations.  She stated that Ontario was “15 years behind the trailblazing Alberta”. And yet the data in the CMAJ article above shows that Alberta has a higher rate of antibiotic prescriptions per capita.

One area I do agree with her is when she wrote:

“the government roll-out video, shot in a noticeable big box pharmacy, didn’t help us”

That big box is Shoppers Drug Mart, and their CEO Jeff Leger is seen promoting this change on the video.   Shoppers Drug Mart recently invested $75 million in Maple, a virtual care company.  Maple’s home page still shows the following:

Screenshot from Maple as of Jan 12, 2023

Gee, if you think you have a sore throat, you can just call a company (that Shoppers invested in), and get an antibiotic without a throat swab (who cares if it’s really strep) and lo and behold, there just happens to be Shoppers nearby that will deliver it to you. Yes, I know patients can request the pharmacy of their choice, but….

Look – there are other aspects of this process that need review.  Accurate diagnosis of a rash for example (several of the new pharmacist powers are for skin ailments). Or communication with the patients family physician about the treatments given.  Probably more.

I WANT pharmacists to help.  I really truly am grateful that so many are willing to step up in a time where our health care system is collapsing faster every day. But I want pharmacists to help in ways that support good health care outcomes.

 Might I offer three suggestions for how pharmacists can do that:

  1. As a group, they can petition Shoppers Drug Mart to put pressure on Maple to change the example on their website.  It’s great marketing (focusing on convenience) but terrible health care.
  2. Get involved with Choosing Wisely, Canada’s leading group looking at all ways to pick the right health care treatments.  There doesn’t appear to be a pharmacist in looking at their leaders.  I think pharmacists could provide extremely valuable information on not just anti-biotic stewardship, but also overall medication management (eg. reducing pill burden in the elderly)
  3. Strongly lobby the government for a unified integrated electronic health system that will allow them secure communication with physicians and access to limited health care data (eg creatinine clearance).  We’ve got this in my neck of the woods, and it’s a huge benefit to physicians, pharmacists and most importantly patients.

In order to save what’s left of our health care system (if that’s even possible now) we need to focus on health care outcomes, and ensuring proper an appropriate care. Doing the three things I listed above would be a big help in that direction.

Open Letter to Nadia Surani, Director, Primary Health Care Branch of MOH

Dear Ms. Surani,

On November 21, 2022 you wrote a letter to primary care organizations requesting that they offer seven day a week availability. For those who may not have seen this letter – I’ve attached a copy for upload here.

The response to your memo has been probably not what you expected. You’ve got one Past President of the Ontario Medical Association calling it dumb. Mind you, that guy always was a bit of a boorish loudmouth. But you’ve got another, much more eloquent past President of the Ontario Medical Association also calling you out on this:

You can’t even say you didn’t know the consequences of your letter, because you’ve got the really smart Dr. Premji warning you against blaming family docs FOUR DAYS before sending your letter:

There’s a lot more upset physicians (and other health care professionals) on social media and elsewhere, but you get my drift. This letter was, to put it far too mildly, not well received. In light of all this, might I humbly suggest that I re-write your letter for you.

From: Nadia Surani, Director, Primary Health Care Branch

To: Family Health Teams, Nurse Practitioner Led Clinics, Indigenous Primary Health Care Organizations

Re: Important Ministry Request

First and foremost, on behalf of the Ministry, I want to thank each and every one of our primary care providers for working tirelessly through the pandemic. I know that there are not enough of you to take care of all the health care needs of Ontario’s residents. Despite that, you continue to do your best and have been working at 110% capacity for longer than seems humanly possible. Your efforts have not gone un noticed and are truly appreciated.

Unfortunately, we are now experiencing a difficult and complex fall season, full of the respiratory illnesses that many of you had predicted. The combination of earlier than expected Influenza A, returning RSV infections and ongoing Covid-19 is pressuring our healthcare system like never before. The paediatric sector is particularly hard hit and sadly, we are expecting high volume pressures across our health system throughout the winter months.

As a result of the above I would like to offer you what support I can to help the residents of Ontario get care during these challenging times. You are all on the front lines, and you see the day to day challenges of providing care first hand. You see the inefficiencies and you see where things can be made better. Many of you may have ideas as to how better manage the flow of patients and many of you have some unique solutions that will help us cope, despite the shortage of health care workers.

Knowing there are limited resources, I obviously can’t promise that we can implement everything suggested. But I want you to know that every reasonable suggestion that will increase the ability of your organization to see patients and alleviate pressure on the health care system as a whole will be considered. If you feel that there will be extraordinary costs associated your suggestions, please contact your ministry representative.

Thank you once again for your ongoing commitment and dedication in the fight against the pandemic and other urgent system pressures. I truly appreciate it and I will do my best to support any innovative solutions you may have.

Please connect with your assigned ministry contact with any suggestions you have for enhancing your organization or any other questions.

Nadia Surani, Director, Primary Care Branch, Ministry of Health

There you have it. I hope that was helpful.

Sincerely,

Your humble servant.

Euthanasia (MAiD) Activists Put A Dollar Value on Human Life

Recently, a patient of mine who I was really fond of, chose euthanasia. The politically correct would prefer to call it Medical Assistance in Dying (MAiD) since it sounds “softer.” But the fact of the matter is we are killing people (presumably to relieve suffering) which is the clear definition of euthanasia. Let’s call it what it really is.

My patient was a nonagenarian, had fairly advanced cancer with probably about 6-9 months left to live. They were still walking (albeit in some discomfort) and toileting independently. They did their own taxes, and anyone who can do their own taxes is mentally competent if not a genius. They looked at the natural course of their illness and, said to me:

“You mean I’m going to spend the last 3 months of my life, likely bedridden with some stranger changing my diapers and wiping my butt?”

And they chose euthanasia, which was provided to them this past year.

The above scenario represents exactly what most Canadians believed they were getting when euthanasia was legalized in 2016. Truth be told, even people like myself, who have qualms about the concept of healers taking lives, completely understand why my patient felt that way. It’s impossible to argue against the autonomous wish of a competent individual.

However, almost as soon as the euthanasia was legalized in Canada, physicians were warning that this was going to open up a slippery slope of ever loosening criteria and increasing permissiveness for euthanasia. Pro Euthanasia types derided these arguments for using “the fear of the unknown“. And yet, six years later, as a nation, we are now on the verge of expanding criteria for euthanasia to include:

And finally, we have a report promoting what many all along thought was the real reason for allowing euthanasia. Basically, that it is cheaper for the health care system.

To be fair, one of the authors of the report, Dr. Aaron Trachtenberg does state that the work is meant to be “theoretical.” He also goes on to state:

“We are not suggesting that patients or providers consider costs when making this very personal and intimate decision to request or provide medical assistance in dying.”

But the blunt reality is that the authors put out a report broadly suggesting to the general public that there are cost savings if, you know, you did the decent thing and just ended it all when you became a burden on the rest of us. Intentional or not, the implication is clear that there is a monetary worth to your life and at some point, you dear patient, are no longer “worth it.” Reminds me of the Star Trek The Next Generation episode “Half a Life“, where the intrepid crew of the Enterprise meets a planet where everyone commits suicide at age 60.

It’s not only people like myself (who have been demanding conscience rights because we saw this coming) that are upset about this. The Toronto Star had a column saying Canada was going too far with euthanasia and warning of the dangers of abuse. The Canadian Society of Palliative Care Physicians has been expressing concern about euthanasia for some time. The Council of Canadians with Disabilities points out that the disabled cannot access supports to live a dignified life but can now access euthanasia. (I’m guessing Dr. Trachtenberg’s report did nothing to ease their concern). Dr. Sonu Gaind, a psychiatrist who himself has done euthanasia assessments has expressed significant concerns about the many flaws in the guidelines for those seeking death when their sole reason is mental illness.

Most tellingly, the National Post reported on a “crisis” in supply of doctors willing to provide euthanasia. Among the reasons cited are the “increased “legal risk and moral hazards” related to ever-widening eligibility.” Also a noted was that many euthanasia providers were curtailing and limiting their practice to those patients for whom the law was originally intended. You know you have a problem when even providers of euthanasia are telling you the rule changes are going too far.

Now perhaps some of the recommendations (like the one around babies) won’t make it through to legality, but the blunt reality is that the slippery slope that was warned about when euthanasia was legalized has come to pass. Its due a combination of lack of foresight and the ineptness of the initial legislation that we are at this place.

It was one thing to allow competent people (like my patient above) to self determine what to do in the face of an incurable illness or suffering. But it’s quite another to recklessly expand criteria . And it the case of those with disabilities, or mental illness, to not provide adequate supports as an option seemingly pushes them in the direction of choosing euthanasia.

Is this really what Canadians wanted?

As for the dollar value of a human life. The study authors write:

“we expect that net health care costs would be reduced by $33.2 million per year if 1% of deaths are due to medical assistance in dying”

This was based on their estimate of about 2,700 cases a year (there were over 10,000 last year). Based on their numbers however, your life is now worth $12,296.30

Get Your Flu Shot…. AND Your Covid Booster.

I’ve written about the importance of getting flu shots before. I continue to be grateful for people who are being pro-active about their health, even if the phone calls to my office asking when the flu shot is coming get to be bit much.

This year there seem to be two main themes in all the phone calls we are getting.

1) What is the ideal interval between getting the flu shot and a Covid booster?

This one is relatively straightforward. The human immune system is designed to handle multiple threats at a time. We can handle multiple vaccines at a time. When infants get immunized at 2,4 and 6 months, they get Tetanus/Diptheria/Pertussis and Polio (and in many jurisdictions Rotavirus and Haemophilus) vaccines all at the same time. We’ve been doing this for decades and it’s served us well.

So getting the flu shot and Covid vaccine on the same day is not an issue. The Centre for Disease Control (CDC) in the United States has clearly indicated this. What is important however, is that the flu shot really needs to be timed properly for peak effectiveness. Again, I’ve written about this before, but the short version is you should get a flu shot in November, so that the vaccine will have peak efficiency during flu season.

If you happen to be due for your Covid booster in November, that’s ok, get both shots at the same time. On the other hand, if you are not due for your Covid booster for a couple of months, please do not put off getting your flu shot.

2) Do I really need a flu shot?

I am hearing this question more often and it saddens me. It is true that the past two flu seasons were relatively mild. The measures we implemented to prevent us from getting Covid (masks, social distancing, etc) also prevented us from getting ALL respiratory illnesses, including the flu. Perhaps people have forgotten how bad the flu can be.

If you have a cough, or the sniffles or a low grade fever, that’s just a cold. It’s not “a touch of the flu”. If you have the flu, in addition to those three symptoms, you will feel like you got run over by a truck twice. The second time because the flu virus will have wanted to to ensure you really really felt it’s presence. Muscles you never knew existed will hurt for days, and it will be an experience you won’t soon forget.

If you are a senior, or someone who for whatever reason has a weakened immune system, the flu will make you more prone to getting a serious complication like pneumonia. You will wind up in hospital, or worse.

With many of the Covid restrictions easing it is reasonable to anticipate that this coming flu season will be worse than the last two years. Australia, which also lifted many Covid restrictions, just came off their worst flu season in five years and their pattern is often repeated in North America. So yeah, anticipate a much worse flu season this year.

Additionally, the number of boosters we need to protect ourselves from Covid seems to increase every few months, and a certain amount of “vaccine fatigue” does set in. I get it, I really do. It can be tiresome to be told you need yet another shot. But you do.

One issue that I have not been asked about, but we should talk about, is what happens if you do get the flu. Hopefully you will “just” be sick for a few days, and then get over it. But unfortunately, we have to consider the possibility that you may get a severe case, and have complications that require you to go to hospital.

I recognize some will accuse me of fear mongering, but in that scenario, you really need to consider the possibility that the care you need (and paid tax dollars for) may not be available. This past summer, media was littered with headlines about this hospitals closing beds, having trouble finding staff and even shutting down ERs. Heck the Chelsey hospital ER is being shut down for months! Do you really think that trend is going to magically end when flu season comes around?

The sad reality is that if you do get a complication from the flu, you may wind up with no one to provide you with the care you need going forward.

What’s the best thing you can do?

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

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

Third, for most other people in the community, wait till November to get your flu shot. This will ensure that we all have a reasonable amount of immunity until the end of the flu season.

Yours truly getting a gentle flu shot from a gentle nurse…

Finally, get the new bivalent Covid booster as soon as you are eligible (for most people it’s three months after their last booster or a Covid infection). Once again, the chance of a true reaction to the Covid Vaccine is exceedingly low. Much lower than your risk of complications from Covid.

Immunizations continue to represent one of our strongest tools to stay healthy. Outside of clean water/sanitation, they are arguably the most successful public health measure in the history of humanity. Let’s all do our part to stay healthy and protect those around us.

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

What Backlogged Health Care Looks Like and How to Fix It.

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.

Does Ontario’s Digital Health Strategy Meet Our Needs?

That the health care system is currently in a state of crisis is no secret. That we need to look at bold, radical transformation of the health care system is no secret. That fixing health care means fixing family medicine first is well known. But in order to do all of this, we must finally fix the mess that is digital health infrastructure in Ontario (indeed, all of Canada).

If you speak to any health care worker about Digital Health/Electronic Medical Records(EMR)/Health Information Systems(HIS) you are most likely to elicit a loud, pain filled groan. EMRs have long been cited as a leading cause for physician burnout. Incredibly, 7 out of 10 physicians (!!) have some form of EMR induced stress.

Even the Surgeon General of the U.S. stated that EMRs needed to be fixed (Dr. Glaumcoflecken’s “there are so many clicks” is the exact response you’d get from me):

The reality however, is that there is a bad way of implementing a digital health infrastructure and a good way.

A bad way would be what the four hospitals in my neck of the woods did last year. Implement Meditech Expanse with it’s cumbersome modules, painful clicks, restrictive algorithms and emesis inducing user interface. Better yet, force doctors to learn this odiously inhumane system in the middle of a pandemic when they were already burnt out. The obvious result? At Collingwood Hospital (where I still have privileges but may not after this blog), many family doctors are leaving citing this as a main cause. (Piss off people who are already burnt out, and they leave, who knew?)

A better way of doing things would be to set things up the way my colleague Dr. James Lane did in (ironically enough) the Georgian Triangle region of which Collingwood is a large part. Set up a system where the whole community is on one EMR. Then allow limited information sharing with allied health care providers. Start with pharmacists, then add in home care providers. As a result, there is secure information sharing between health care providers allowing the optimization of patient care.

Some recent examples from my practice:

  1. I renew a prescription for amiodarone. The pharmacists messages me back on the patient’s chart (no faxing, no finding the chart etc) letting me know that the cardiologist had actually reduced the dose of the amiodarone, and I immediately correct the prescription.
  2. The wife of a patient with dementia is concerned her husband is deteriorating. I send a message via my EMR to the Home Care case manager assigned to my practice. I get a response by end of day saying she’s contacted the wife and will arrange for an in home assessment. (This doesn’t solve the problem of actually finding staff to do the work of course, but at least I know that the referral hasn’t been lost).
  3. I send a CT requisition to radiology for staging of a newly diagnosed cancer patient. The local radiologist has questions so he accesses the chart to look at some of the pathology reports to inform his report of the CT.

There’s many more examples but you get the point. These kind of things can not only enhance patient care, but reduce the admin burden of co-ordinating between different agencies. (I cringe when my friends in other centres talk about how hard it is to get home care to acknowledge that they received a referral much less to do something about it).

But this can only happen if the Digital Health team at the Ministry of Health has the vision, the boldness and the fortitude to force these changes and frankly, I’m not sure they do. I had meetings with some of the Digital Health team when I was OMA President. They are well meaning people who want to improve things. But the strategy they are choosing is doomed to failure.

I probably shouldn’t mention this as it was a closed meeting, but I don’t care any more, and besides, what can they do to me? Stop me from running for OMA President again? One of the senior members of the Ministry’s team explained their strategy to me like this:

“If I want to buy a pair of shoes, I have three apps on my phone that allows me to compare different prices from different vendors, and then I choose the best price. Patients should do that when they access health care.”

Now this fellow was in his 40s, and a university graduate. Clearly he can access multiple apps. Good for him.

But the highest users of any health care system are the seniors and the reality is that they are not as technologically able as our friendly government bureaucrat. Do we really expect an 80 year old with multiple medical problems to flip through three apps if they need health care? What if the apps only access part of the system? You’d need one app to access their family doctor, another to access the hospital and a third to access home care. Would anyone want to do this?

All this will do is increase the plethora of software out there, cause more confusion and a deteriorate the communications between health care providers and add to the work load of physicians (because, you know, we are not already doing enough clerical work).

What about OntarioMD? Aren’t they supposed to advocate for change that will help physicians? I had issues with OntarioMD when I was on the OMA Board. (Long story for another day).

But I do note with interest that OMA Board Chair Dr. Cathy Faulds announced in her Board Report that there is a new mandate for OntarioMD that includes end to end proof of concepts on policy. I personally won’t hold my breath (one bitten, twice shy) but I do acknowledge it’s a step in the right direction. Maybe they can finally get on with some of the work that I advocated for during my term and relieve some of the burden that physicians deal with.

It’s the 21st Century. We still can’t fix the health system without fixing family medicine. But we can’t fix family medicine without fixing digital health. Here’s hoping the powers that be finally realize that.

Will More Canadians Resort to Medical Tourism?

The health care system in Canada has been in a perpetual state of crisis for a couple of decades now. But I’ve never seen it this bad before (and I’m old, I’ve seen a lot).

Across the country, Emergency Departments are restricting access and having partial closures including not just one, but TWO hospitals, in the nation’s capital for crying out loud. Urgent care centres, ICUs and medical wards are also facing issues with staffing shortages and Covid outbreaks.

Even when health facilities are open, we face ever increasing wait times. We wait in line at after hours clinics. We wait for hours in ERs. We wait for months if not years to see a specialist. And we wait and wait for procedures that bureaucrats call “elective”. (NB not sure how cataract surgery, which helps people to see properly, or joint replacement, which helps people to live pain free can be classified as “elective” – but then again, I never understood how bureaucrats classified anything).

With the recent BC court ruling indicating that patients cannot be allowed to pay for private care (putting us in the same group of countries as Cuba and North Korea) – Canadians will have to be the most patient people on Earth.

Or maybe not. We are now starting to see governments, and people, take matters into their own hands.

Saskatchewan recently unveiled a program where they would pay for patients to have their hip and knee procedures done in Alberta. The catch? Patients would have to pay for their own travel costs. A very cursory glance at Westjet’s website suggested this would be just over $1,000 per person for a return flight from Saskatoon to Edmonton. Hotels/car rentals and food would be extra.

It’s not just governments. “Adele” from Hamilton couldn’t bear to see her partner deteriorate as he languished on a wait list in Ontario for hip replacement surgery that might happen by February of 2023. The couple paid $20,000 out of pocket to have the surgery done privately in Quebec on August 23, 2022. I can’t say I blame them. I’ve seen patients suffer from daily pain. It’s heartbreaking.

It all makes me wonder. Are we about to see an explosion in Medical Tourism as patience wears thin?

Travelling to foreign countries for medical procedures is not a new concept. In the cosmetic surgery field, the most famous example would be Costa Rica. A random look at some of the information out there suggests that you can save about 50% off what you would pay in Canada for similar surgical procedures, and that includes accommodations and travel.

Another up and coming country in the Medical Tourism field is Turkiye. Turkiye has a very positive reputation in the male 50+ South Asian community for hair transplants. A quick look at hair transplants in Toronto suggests that while prices vary, costs begin at $8,000 and most people will pay much more.

In Turkiye, on the other hand, the average cost of a hair transplant is 2,350 Euros (about $3,000 Canadian) and that includes accommodation/meds/transportation from the airpot/follow up etc. Some clinics charge less, and some more, but the point is that you can largely save 50% of the cost of doing this in Canada.

It’s not just cosmetic surgery, however. Turkiye is making a name for itself as a medical tourism centre for Europeans. In the bigger Turkish cities, private hospitals offer services in English. The cost of a hip replacement varies depending on the severity and type of joint used. It’s usually between $7,500 to $20,000 Canadian and that includes hotel accommodations, travel to hospital and food. Far cheaper than the United States.

Knee replacements also vary depending on what’s needed, but the average seems to be $9,800 Canadian. There’s a whole list of elective surgical procedures that are done in Turkey that people can find with a little bit of searching.

Why is Turkiye so popular? According to passport symphony.com, it’s a combination of Turkiye’s private hospitals having invested heavily in medical infrastructure over the years and the fact that Turkiye has beautiful and scenic sites so you can have a mini – vacation at the same time. Add to that that Turkiye has aligned its health care to meet European Union (EU) standards (particularly with Medical Devices and Implants) and you have the potential for the highest quality health care at a much lower cost.

Don’t underestimate the importance of aligning with EU standards by the way. Many other medical tourism destinations (Caribbean, Asia) have wildly varying standards. It can be hard to determine what quality of service you are getting. At least if you have EU standards in the facility you are getting treatments done, well, there’s a reassurance of a certain standard of care.

Now to be clear, there are always risks to surgery, especially if you leave the country. Even the best hospitals and surgeons have complications. If you are considering exploring surgery out of Canada, two rules apply:

  1. Caveat Emptor
  2. Contact a trusted agency to help find the best, approved facilities and surgeons.

For Turkiye, you should contact the Canadian Turkish Business Council. Their job is to promote business in Turkiye, and they can provide you with information on which hospitals and specialists are appropriate for you to consider. I understand they can also help with flights.

I imagine there are such organizations for some of the Caribbean countries as well.

I recognize that many Canadians will be offended by the idea of paying for essential health services elsewhere. Our tax dollars are supposed to pay for those services here. But decades of mismanagement of our health care system have left many people languishing on wait lists, and the reality is it will take decades to fix.

It would not surprise me in the least if more and more Canadians looked to Medical Tourism as a way of relieving their suffering quicker than the Canadian system allows.

CMA Should Do What’s Necessary – Advocate for Pensions for Physicians

Both of my loyal readers will know that I have not always been a fan of the Canadian Medial Association (CMA). I was one of the vocal critics of the infamous Vision2020 plan that the CMA developed. Vision 2020 suggested that the main role of the CMA should be to empower patients (and here I thought they were supposed to be a physicians advocacy organization). I also wasn’t really impressed by the sale of MD Management to Scotia Bank either.

Interestingly enough I note that the original links in my blog to the articles on Vision 2020 and the MD Management sale have been deleted from various CMA websites. Such scrubbing suggests the CMA would rather we all forgot about these things too.

It would seem that I am not the only physician who was upset with the CMA. Buried deep in the CBC article on the election of Dr. Alika Lafontaine to the role of CMA President is this line:

“As CMA president, he’ll oversee more than 68,000 member physicians and trainees.”

When Dr. Gigi Osler took over as president in 2018, this Globe and Mail article stated the CMA had 85,000 members. A drop of 17,000 members in four years shows that rather a lot of physicians felt that the CMA betrayed them, not just a loud mouthed old country doctor.

In fairness, since 2018, the CMA has done some things very well for physicians. First, the CMA has had some truly excellent Presidents in Dr. Gigi Osler and most recently Dr. Katharine Smart. While I completely understand the significance of Dr. Alika Lafontaine taking over as President, I was saddened about losing a voice as effective for physicians as Dr. Smart. However, I will say that Dr. Lafontaine knocked it out of the park during his inauguration speech and if he keeps that up it will good news for physicians across Canada.

Drs. Gigi Osler, Katharine Smart and Alika Lafontaine

Secondly, the CMA seems to be making its main priority these days the issue of physician burnout. A brief look at their twitter feed shows them reaching out to multiple media outlets to raise awareness of the alarmingly high burnout rates in the profession.

This is good work and shows an organization that maybe has realized that indeed, there is nothing wrong with advocating for physicians. You cannot have a high functioning health care system without happy, healthy and engaged physicians.

As part of the approach to alleviating the stress on physicians and the broader health care system, the CMA also is advocating for a national licence for physicians. The CMA feels this is a priority and a glance at an advanced search of their twitter feed suggests that they feel this will improve virtual care, increase the ability of physicians to support remote communities and reduce burnout.

Now to be clear, I support a national licence for physicians. But the reality is that this is going to be nigh on impossible to do in the short term. I suspect that this will require an amendment to the Canadian Constitution as Health Care is provincial responsibility. Amending the constitution is a dizzyingly complex process. I suspect that Premiers of what may be considered “have-not” provinces would balk at this, fearing that national licensure would lead to more physicians leaving their provinces for greener pastures.

Instead, I would ask that the CMA employ the philosophy espoused by St. Frances of Assisi:

“Start by doing what’s necessary; then do what’s possible; and suddenly, you are doing the impossible.”

The CMA should advocate for immediate Tax Code changes to allow physicians to have pension plans. This is both necessary and long overdue.

I do feel compelled to point out that it is possible for physicians to set up either retirement plans or individual pensions through corporations. However these programs are extremely variable, not easy to implement, and carry high administrative burdens. They also add to physicians workload to set up, at a time when physicians are so tired from a days work that they don’t really have time to think about such things. I don’t know about you, but when I get home, I want to turn my brain off for a couple of hours (before I log back on to my EMR to review lab work and finish charting). I don’t have the mental bandwidth to think about corporate pension schemes.

Making a few changes to the Tax Code is easy. It can be done at the federal level without involving the Provincial Premiers. Doing it will send an immediate message to physicians by the Federal government that they are doing something right here, right now to make life easier for physicians and reward them for all the extra hours they have worked during the pandemic. It will significantly improve physician morale. As physicians realize that there will be an element of security in retirement planning, it will also reduce the stress level of physicians.

Even better, some provinces have already started retirement planning programs. Ontario for example, has the truly excellent OMA Insurance Advantages Program. (NB – if you are an Ontario physician, you really need to strongly consider enrolling in this program. It’s simple, straightforward and really can take a lot of the usual retirement worry away). If tax code changes came into effect, I’m sure a few lawyers and accountants could convert these programs into true pension plans.

The CMA is a national advocacy organization for physicians. They have made much progress since 2017 in supporting physicians. The next, easiest step for them to make would be to push for physicians pensions. It’s relatively easy to do. If successful, maybe they can turn around the trend of declining membership in their organization.

Most Health Care in Canada is Publicly Funded, Privately Delivered

NB: My thanks to Dr. Hemant Shah, who inspired the title of this blog with his statements on health care delivery in Canada.

Well, here we go again. Yet another kerfuffle caused by absolutist ideologues who are so hell bent on forcing their immovable views on the rest of us that they are resorting to fear tactics.

Ontario Health Minister Won’t Rule out Privatization as Option to Help ER Crisis” – screams the headline in the Toronto Star (a newspaper known for its extremely biased reporting on health care). The article comes after Ontario Health Minister Sylvia Jones had a press scrum. The only problem is that’s not quite what she said.

Here’s the tweet from Mark McAllister, who embarrassingly reached a similar conclusion in his summary:

At no point does the Minister say she is going to privatize Emergency Rooms. Her quote is:

“Look, we’ve always had a public health system in the province of Ontario and we will continue to do so.”

Exactly what part of this screams “privatization”? Even the snippet after where she refers to looking at “options” she clearly mentions other jurisdictions in Canada, where, you know, you have public health care.

The reality is that public health care is for the most part, privately delivered in Canada. Take your family doctor for example (assuming you are lucky enough to have a family doctor). Supposing you go to your doctor to get assessed. In Ontario, your family doctor will likely get paid $36.85 (see page A5 on the Schedule of Benefits). Out of that $36.85, your doctor will allot some of it for the receptionist, the nurse, the cleaners, the rent, the computers and so on. The remainder is the profit, which you family doctor will keep for themselves.

Your family doctor is a private business.

The infuriating thing about this kerfuffle is that this kind of absolutist, hyperbolic nonsense has prevented real advances in health care over the past twenty years. Every time there is a new proposal on how to look at health care differently, some nitwit politician screams out that we are opening the door to two tier American style health care. The new idea gets shut down without taking a thorough look at its merits.

It’s the rigid, inflexible thinking by geniuses like Jagmeet Singh that prevent any such exploration of new ideas. Just have a look at our hospitals. We currently have a crisis with our hospitals over capacity and many waiting in ERs for beds. Yet we still do procedures in hospitals that could be done elsewhere, and free up hospital capacity.

For example, there is ample evidence that independently operating cataract surgery clinics are more efficient and can cut cataract surgery waiting lists. In Canada, these clinics would have to be funded by public health insurance. All absolutists like Singh see is that procedures will be done in a “private” clinic, and are therefore un-Canadian and Tommy Douglas must be rolling in his grave to hear of such a possibility.

Fun fact: Tommy Douglas supported user fees for health care.

Singh and his absolutists would rather you go blind on 2 year wait lists than have publicly funded health care done in a way they don’t approve.

To be completely fair, there are some legitimate concerns about doing procedures in independent clinics. For example, there was concern that colonoscopies in outpatient settings were suboptimal. However, those concerns were addressed by some needed changes made by the College of Physicians and Surgeons of Ontario, with the setting of minimum standards and inspections. As a result of that, there was a strong feeling that colonoscopies could be done safely and efficiently outside of hospitals.

And let’s face it, it’s not as if public institutions are without issues either. Remember the time there was concern the Niagara hospital mishandled a c.difficile outbreak? Or the public nursing home that has been shut to new admissions for over a year? In fact there’s a suggestion that harm to patients in public hospitals costs $1 Billion a year.

No matter if public or private, so long as human beings are involved, mistakes will get made. What’s really needed is a way to do appropriate inspection and review of facilities that are funded by the public purse, so that mistakes are minimized. Then let them get on with their jobs.

What I don’t get is how these folk don’t recognize the hypocrisy of their views. In their mind, it is okay for a family doctor to bill OHIP for a blood pressure check, then use that money to pay for their clinic and keep the profit. But it’s not okay for a gastroenterologist to bill OHIP for a colonoscopy in a health facility (which is safe to do), and use that money to pay for their clinic and keep the profit. Or for an ophthalmologist to bill OHIP for a cataract removal out of hospital (also safe to do) pay for their clinic and keep the profit. And they accuse Sylvia Jones of promoting two tiered approach to medicine???

What about the fact that these private clinics charge patients for some things? Um…..have you ever gone to your family doctor for a Driver’s Medical? You know it’s not covered by public health insurance right? And you have to pay your family doctor for it? How about a sick note? An employment form? The reality is that ALL clinics will charge you for things that public health insurance won’t cover.

As our health care system continues to collapse all around us, we need to take a thoughtful, intelligent and open minded look at how we deliver health care. Yes it should be paid for by the public purse. But we need to recognize the reality that appropriately funding private clinics (with levers to ensure high quality care) is the most effective way start clearing the immense backlog of health care cases.

As for absolutists who snarl at the mere mention of the phrase “private”. While everyone with a modicum of intelligence recognizes that Star Trek is a much better franchise, let me leave them with this from the other, weaker franchise: