Category: Burnout

Marcus Welby Couldn’t Handle Today’s Medicine

This blog originally appeared in the Huffington Post on May 2, 2016. Reprinted here so that I can keep track of my old blogs, and also to once again point out how warnings of a crisis in Family Medicine were ignored for years.

Recently, Globe and Mail columnist Gary Mason lost his family physician to retirement. In an eloquent post, he reflected on how much he was going to miss his physician of 22 years, and how difficult it was to find himself in the position of not having the family physician. Unfortunately, as he pointed out, a growing number of Canadians are finding themselves in the same position.

Understandably concerned about his predicament, and wanting to know what’s going on, he did what most reporters and politicians do to find out about health care. He asked a health-care policy consultant, in this case Steven Lewis.

As an aside, it never ceases to amaze me how when people want advice with what’s wrong with health care, they always turn to health care consultants. Why not just ask a physician instead? If I have a leaky faucet, I don’t ask a Water Flow Policy Analyst from the Ministry of Environment what’s wrong. I call a plumber.

At any rate, I happen to think that Mr. Lewis gave Mr. Mason some pretty bad advice. Mr. Lewis suggested that newer Family Docs were incentivized to “do less.” This led Mr. Mason to opine that “in other words, Marcus Welby is dead.”

While I agree the situation is complex, the main reason that younger family physicians are taking fewer patients has nothing to do with either a lack of dedication or desire to help their patients, but rather that medicine has become far more complex in the past 30 years.

The past 30 years have seen an exponential increase in the number of screening and preventive care tests, all of which the family physician is expected to order.

For example, when I took over my current practice 24 years ago, I recall looking at one patient’s chart, and seeing the notation: “April 26, 1990. Strep throat. Penicillin.” This was clearly all the family physician at the time, really needed to know. However, there is no way on God’s green earth that you could get away with such a note in this day and age.

Since the 1990s there been a number of regulations on documenting patient visits set by Provincial Colleges and physician funding agencies (eg. OHIP in Ontario). In principle, the rules are put in place under the very reasonable rationale that there needs to be some accounting for spending public funds, and that documentation will prove those funds were spent wisely. In practice, that means that even a notation for such a simple problem, requires a minimum of four to five sentences in the chart. All of which means that there is less time in the day to see patients.

Additionally, contrary to what Mr. Lewis has told Mr. Mason, the responsibilities of the average family physician has actually increased since 1990. The past 30 years have seen an exponential increase in the number of screening and preventive care tests, all of which the family physician is expected to order.

For example, we never used to do bone density test on men. These were exclusively a test done on women, as they were thought to be at higher risk for osteoporosis. The guidelines have changed and now men over 50 are also being tested based on certain criteria.

In the past week, I have had six bone density results, four of which came back with a diagnosis of “low bone mass,” which require the patient to be called back, and counselled on the importance of the intake of dietary calcium, and vitamin D, weight bearing exercise etc, to preserve bone health and reduce the risk of fractures as patients get older.

I happen to be one of the relatively few physicians in Ontario lucky enough to have a superb Nurse Practitioner working with me, and she is really enthusiastic about counselling patients about these type of lifestyle changes. As a result, I am able to get patients to see her to learn about these lifestyle issues while I deal with some more complex cases. I appreciate that this may seem to be a “clinic” to Mr. Mason, but it certainly does maximize the value of both my time and hers.

Similarly, we now screen (in appropriate patients) for aortic aneurysms, colon cancer, breast cancer, diabetes and several other diseases. All of which require more time per patient, and result in abnormalities found, which result in time required to address those abnormalities.

One of the benefits of having an electronic medical record system, is the you can program them to have the system remind your patients when they are due for appropriate screening test. This could never be done on the old patient’s chart. 

Recently, a patient came in to see me with a sore foot. Marcus Welby would undoubtedly have looked at the foot, and wrote in the chart: “Gout. Indomethacin.”

In contrast, my note documents when the pain started, that there was no history of trauma, a review of previous blood work to check his uric acid level (a contributing factor to gout), whether the neuro-vascular status was affected, how far up the foot the redness goes, and his vital signs. To which I add, “Assessment: Gout, Treatment: Indomethacin.”

At his visit, I also looked at the reminder screen of his electronic chart. I’ve included a snapshot (with personal information removed) of what I saw.

So now, not only did I treat his gout, but I ordered all of the investigations this fellow was due for (he tends to avoid coming to see doctors). If you do this on enough patients, you will find abnormalities, which will then require follow up.

Lest you think I’m complaining, let me categorically state, all of this is a good thing. Reports have shown that investing in primary preventative care, is good not only for the patient, but also for the population as a whole. These are wise investments to make, as they prevent far more expensive complications from occurring in the future. It’s like that old commercial about getting your oil changed on time in your car. You can either pay a little now, or pay a lot later. 

However what it also does a significantly increase the workload per patient per family physicians. Which means it is no longer possible for a family physician to look after the same number of patients as Marcus Welby did. It is not as Mr. Lewis was quoted as saying “A desire to do less”, rather the work per patient has increased.

I’ve generally enjoyed Mr. Mason’s columns in the Globe and Mail. I wish him well in his quest to find a family physician. If he moves to my neck of the woods, I would probably consider taking him on, if only because I rather enjoy funny stories and debating politics with people. As a bonus, I don’t drink, so Mr. Mason would not even have to give me the expensive bottle of scotch he promised. (I would however, demand some inside dirt on his fellow columnist and health care reporter Andre Picard!)

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The Admin Burden That’s Really Killing Family Practice

Recently, there’s been a lot of talk about the “administration burden” faced by family physicians. The Ontario College of Family Physicians estimates family doctors spend up to 19 hours a week on “paper work”. Given there are only so many hours in a week, the more hours spent doing paperwork, the less hours seeing patients.

It also contributes to situations where people just get too frustrated with family medicine, and quit. Twenty percent of Toronto family doctors are planning on leaving within five years. This bad karma is not lost on medical students, who, as I mentioned in a previous blog – are avoiding family practice like the plague, worsening a crisis that has been years in the making.

But what exactly is this “administration burden”? What’s the “paper work” that is driving us all to frustration? I would argue it’s not paper per se, it’s digital.

That’s not to say there isn’t paper. I frequently get asked for completely pointless sick notes from employers, impractical forms to return to work and seemingly useless – “we agreed your patient was permanently disabled, but we want a one year update to make sure your patient is still permanently disabled” forms from the pointy headed bureaucrats at insurance companies. But I’ve taken a somewhat mercenary approach to those forms in order to keep myself sane.

A sick note costs $20 and takes about a minute to write. A form the insurance company asks for usually takes a few minutes to fill out and I charge $40-$175 depending on the form. I reconcile the fact that these forms are a burden, with the fact that at least I make money out of them. While somewhat unscrupulous on my part, it keeps me from totally blowing my lid whenever I see one of these.

No the real admin burden comes from the completely absurd and unrelenting avalanche of reports/lab work/follow up notes – all of which present to me in a haphazard way, seemingly designed to drive me to psychiatric medications.

I took the Friday of Eid ul Fitr off to celebrate with my family. On Saturday, I logged into my Electronic Medical Record (EMR), correctly realizing that if I waited until Monday, the EMR inbox would crush my sorry soul.

Unsurprisingly, I had a total of 75 labs/reports/messages about patients to review. It wasn’t so much the number of items to take care of, (truly if they were straight forward it wouldn’t have been too bad). It was rather how badly and inefficiently the information came to me that sucked all of the happiness I had enjoyed on Eid from my spirit.

One method of getting information to me is via a system called Hospital Report Manager (HRM). I look at HRM in my EMR and see a report on a renal transplant patient from Sick Kids. But the note was “uncategorized” which meant that I had to go into the HRM software and enter the category “nephrologist” in the report. The VERY NEXT report in my HRM in box was……the exact same report on the exact same patient, but this time HRM had categorized the report as being from a cardiologist – so I had to go in, change the report once again to “nephrologist” and I now have two copies of the same report.

By the way – Sick Kid’s hospital provides exceptional medical and nursing care to my patients, but ever since they switched their hospital IT systems to a company called EPIC there has been no end of issues like this. The only thing that software is epic at is causing physician distress.

That’s not all. HRM has more goodies awaiting for me. There’s a report from my colleague Dr. Collings on his expert management of a wrist fracture on one of my patients. Thorough, comprehensive, and well done. Except HRM has auto-categorized him to be a gynaecologist So yes, I either have inaccurate information in my patients chart, or I go back and re-categorize the report to reflect that Dr. Collings is an orthopaedic surgeon.

Next up, HRM has a report from an Emergency Room physician about a patient who was seen and apparently had some abnormal bloodwork. Not life threatening, so asked to follow up with me. Only problem is the blood work from the hospital doesn’t come to me via HRM. Now I have to go to that patients chart, and access yet another system called OLIS, log into that and download the lab work from the hospital. But wait the note from the ER was unfortunately late getting to me (about 10 days out). OLIS is set up to auto download for the past seven days, unless I click more buttons, and back date – which I have to do.

Next up, a report from HRM that a patient of mine had a Covid swab done. But HRM won’t tell me if the swab was positive or negative. Just that it was done. Now I go back to that patient chart and access OLIS where the result is, adding yet more steps to my day.

Next come messages (yes, that’s on top of HRM and OLIS). I note a message from the local Shoppers Drug Mart asking for a renewal of blood pressure medications for a patient of mine. Only problem is that a brief look at the chart shows I sent a one year supply of that same medicine to the Shoppers three months ago, and they accepted this and downloaded it. I tell the pharmacy staff who tell me they “can’t find it” which leads to……well, let’s just say a deterioration in the conversation.

As an aside, while I’m not allowed to endorse any specific pharmacy, I will say I’ve generally found care to be much better when provided by smaller, independent pharmacists who build relationships with their patients, rather than big chains that just seem to fly in itinerant staff.

Anyway, you get the point. In total it took about 3 hours on Saturday to sort through this mess and it just doesn’t have to be this way. The reason I wrote a blog about Health IT in Turkiye was to show that other countries do a much better job of managing this burden. I’m sure there are other examples and we need to learn from them.

The vast majority of my family practice colleagues practice family medicine because they genuinely like their patients, like providing comprehensive care, value the relationships built over time and feel like they make a difference in peoples lives. But unless we do something about this administration burden, I fear more and more will leave the profession, because at some point, being human, they just won’t be able to take it any more.

What if We Didn’t Lose the Doctors We Trained?

Canada is in the midst of doctor shortage. In particular there are at least 6 million Canadians with out family doctor. The situation is worsening. The most recent Canadian Residency Match for medical students applying to specialties, showed that there were 268 empty spots for family medicine after the first round. This is the highest number of unmatched family medicine positions ever. Medical Students, being really smart people, are viewing family medicine as a dead end specialty and avoiding it like the plague.

If only the boorish loudmouth who predicted we were heading in this direction six years ago and been listened to…..

Governments at both federal and provincial levels are taking steps to try to address this. In British Columbia, they have introduced a capitation based payment model for family physicians (think of it as salary + performance bonuses). Ontario has a model like this that had great success in the early 2000’s. The federal government pledged more spending on health care in the future. Ontario plans the “largest expansion of medical school education in ten years.” And so on.

But what would have things been like if successive governments didn’t drive doctors away from Canada in the first place?

Going back as far as the 1990s, inept governments have, over the years, done their best to make physicians feel unwelcome. The Bob (“I am super elite“) Rae NDP government of 1990-1995 in Ontario implemented the Barer-Stoddart report. This report decided “there were too many doctors” (I kid you not) and cut medical school enrolment by 10%. Three decades later we are still feeling the adverse ramifications created by that move.

Similarly, the disreputable Kathleen Wynne Ontario Liberal government went to war with physicians in the mid 2010s, led by her woefully incompetent Health Minister Eric Hoskins, and his inept sidekick, Deputy Minister Bob Bell. Those geniuses thought it was a good idea to CUT 50 residency positions (training for doctors) and only saw the light during a deathbed confession just in time for the 2018 election. In particular, Hoskins and Bell’s blatant disregard and borderline contempt for family physicians resulted in, as OMA Vice-Chair Audrey Karlinsky put it, 6 years of family medicine graduates not choosing comprehensive family medicine.

Do you think supporting hundreds of those young potential family docs then would have made a difference now when 2.2 Million Ontario residents are without a family doctor?

To prove that idiocy in health care management can occur with parties of all political stripes, the former Alberta Conservative Health Minister, the combustible Tyler Shandro, actually verbally attacked a physician at his home in Alberta, along with, you guessed it, going to war with physicians in his own province. Really helps to retain physicians, no?

In my first ever blog for the Huffington Post (seven years ago!), I pointed out to then Health Minister Eric Hoskins that 30% of my graduating class no longer worked in Ontario due to Bob Rae’s intransigence. I urged Hoskins to change his behaviour or that by the time of the next election, health care would be in a worse crisis and hinted his government would pay the price in the 2018 election. (I wonder if Kathleen Wynne regrets sticking with him as health minister for so long, despite the fact he was obviously not up to the task).

Admittedly, that’s one person’s recollection. Are there any statistics out there that show just how many Canadian trained doctors have left Canada? There are, although they are really hard to come by, and not as up to date as I’d like. Huge shout out to Dr. Mary Fernando for digging these up for me.

In 2000, the OECD published a report on the mobility of health care professionals. On page 50, it indicated that 19% of doctors born in Canada were working in other countries. Given the crisis we see in health care around us right now, do you think it would help if we could have retained those doctors in Canada?

But wait, aren’t we trying get international medical graduates (IMGs) to come to Canada? Ontario health minister Sylvia Jones did direct colleges to come up with a way to speed up the ability to get foreign doctors licensed. But it turns out we have trouble keeping them as well. A study on retention patterns of IMGs in Canada showed that 12% of IMGs were approved to practice in Canada between 2005 and 2011 LEFT Canada by 2015. While IMGs apply, we have trouble retaining them too.

Clearly, governments need to focus on retention of physicians just as much (if not more so) than recruiting new physicians. What can they do?

The federal government can do a couple of things to help. First it can heed the results of a poll taken by the Medical Post magazine (I voted just before closing and these were the results):

Doctors don’t have pensions and benefits mostly due to some weird federal tax laws. Changing these should be easy and offering pensions and benefits would be a strong way to retain physicians. Similarly, reversing the 2017 tax changes that completely threw retirement planning out the window for doctors would be a big help.

Provincial governments should of course, take note of the fact that going to war with doctors always leads to a deterioration in health care for the residents of their province. But since most politicians are incapable of thinking about anything but their own self interest, let me point out three facts.

In 1995, after going to war with doctors, the Bob Rae NDP government was turfed from power in Ontario and the NDP has yet to form a provincial government since. In 2018, after going to war with doctors, the Kathleen Wynne Liberal government was decimated in the Ontario election, even losing official party status, which they have yet to regain. In 2022 after going to war with doctors, Alberta Premier Jason Kenny had to resign as premier because his own party saw the writing on the wall.

The message is clear. Going to war with doctors is bad for health care and bad for political careers. It’s time politicians realized that, and came up with meaningful solutions like pensions to retain the ones we train.

Canada’s Health Care Landscape has Changed Since the Canada Health Act

I’m honoured to have Dr. Silvy Mathew guest blog for me today. She’s a former member of the OMA Board, former member of the Physicians Services Committee, has a Master’s in Health Policy and Economics, a Certificate in Global Health and is hands down one of the smartest people I know.

Health care in Canada is governed by the Canada Health Act, a federal act that essentially states that medically necessary care provided by physicians and hospitals, will be covered by public insurance and administered by each province. 

The Act was passed in 1984, and is reflective of the type of acute medical care practiced at the time. However, in 2023 (and for at least a decade prior), medical care, through technology, medical advancements and aging, has changed drastically. Publicly covered care now, however well intentioned, is sorely lacking. Ironically, because of that, it is also very expensive.

For exampe, we lack public pharmacare  for adults despite being promised this by 2006 by then Prime Minister Paul Martin. (There is some pharmacare for seniors and children).

We lack dental care. We lack appropriate home care in an aging population that is getting weaker and frailer. We lack coverage on physiotherapy. In an era of increasing mental health burdens we lack psychotherapy.

The list goes on and on, notwithstanding the severe social issues that contribute to many of these issues (healthy food, exercise, housing and all the other social determinants of health).

Because we have not invested upfront, we pay significant costs in expensive procedures, prolonged hospital stays, and medications much of which could be minimized or avoided.

Why does it matter?

McKinsey Global Institute published a prospective analysis of 200 countries, looking forward on the impact of 52 diseases over the next two decades to quantify the social and economic gains if health is made a priority by government and private sector.  They quantified the value of health to the economy and showed that if using the existing interventions we have today, we can reduce disease burden by 40% in the next 20 years and extend “active middle age by 10 years”. This translates to an economic return of $2-$4 for each $1 invested. That’s remarkable. 

What’s the hold up? The lack of foresight, upfront cost and political inertia is costing us.

We have a shortage of healthcare professionals, and we use the ones we have, in extremely inefficient ways. For example, the lack of a proper digital health infrastructure in Ontario (like they have in Turkiye!) results in duplication of services, poor coordination, and inconsistent delivery of health care. Even the electronic services we DO have don’t capitalize on Artificial Intelligence (AI).

Technology advancement is a double edged sword. There are benefits to patients in terms of ongoing updated guidelines for care. But health care workers are having to do more, monitor more and change practice styles more, all leading to more individual HCW time.

Each test, often results in further testing or reassessment down the line, which compounds the problem. It’s rare that physicians just close the door on one issue a day.

Again, at the time of the Canada Health Act, we were practicing acute, limited health care. Today’s world is focused on prevention and chronic illness with monitoring. That shift has placed a huge burden on physicians time to review, inform/educate, coordinate new referrals and remind individuals to do monitoring.  Much of the time, it seems like we still don’t know how much benefit we will get from this. Hopefully the data will show we were correct to do this.

To collect and review the data though, we would need better digital systems to capture the information, which we don’t have.

Some people imply this will be managed with more “healthcare team members”. I think a huge solution for this particular issue is investing in technology and AI solutions.

Right now, we are trying and failing at holding back an avalanche.  We have technological advancements, but limited access to those. We have lack of integration of our digital infrastructure. An ageing population is leading to increased needs. But an aging health care work force is seeing retirements and illness leading to less access. New providers are available but their impact is less clear due to lesser training and duplication of services leading to increased costs. Delayed diagnoses are leading to worsened health outcomes and more expensive care. There is less preventative care due to a shortage of family physicians which leads to delayed diagnoses, worsened health outcomes and more expensive care. Lack of care giver support and home care support means that people are leaving the workforce to care for ill relatives which leads to hospital dumping. Burnout is endemic in health care, due to a feeling of disrespect and an inability to practice best patient care.

And so, physicians are in all areas of the country are giving up and closing their practices.

In the meantime, while we wait for our wishes to come true, there is opportunity to push the envelope and to drive change. People are desperate and they want options.

When access to health care is inadequate, people will choose out of jurisdiction options for delayed procedures and even screening tests. There is a moral hazard involved. People are taking risks by going elsewhere under the assumption that they will be taken care of properly.

However, with any challenges, there are opportunities. Some “non-medically necessary” medical tests (eg. screening for vitamin D) are not covered by medicare. However, it’s increasingly viewed as an early intervention. We will only see technology increase these options as better screening methods become available, and governments delay paying for them. Perhaps instead of waiting for open heart surgery or stenting, there may come a day where preventative procedures can be used to dissolve plaque in the heart arteries.

Health care faces inescapable and exponential change. However, it is unlikely, at least in the near future, that Canada (or any country’s) public health system will be able to keep up with technology and demand.

Oh for some strong, principled leadership that can see these challenges and address them head on, without resorting to political sound bites.

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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.

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.

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.