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

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:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What does all this mean?

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

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

Governments Should Listen to the Experts and Ease Covid Restrictions

It’s time.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It’s time to start lifting.

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

CMAJ Disgraces Itself By Publishing Islamophobic Drivel

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Time will tell.

Corporatization of Medicine Continues Unabated

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

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

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

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

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

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

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

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

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

Screen shot as of Dec 6, 2021

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

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

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

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

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

Pharmacies Must Put Corporate Interests Aside to Give Flu Shots

October is just around the corner. Leaves will soon be turning magnificent colours. Pumpkin Spice treats will flow in abundance from many cafe’s. Plans to have a safe Halloween will be afoot. And – the inevitable cry of “when can I get my flu shot?” will be increasingly heard at many physicians offices.

Last year, there was a significant rise in the number of people who got a flu shot. While our flu season was mild last year (likely because of a combination of all the social distancing/mask measures and the higher vaccination rates) – there is concern this season may be more severe. In order to minimize the severity of this years flu season, we need to continue the trend of more people getting flu shots.

But last year was also the year that there was a lot of confusion around flu shots, and the year that the increasing commercialization of flu shots by the corporate head offices of pharmaceutical chains raised big concerns for me.

First, the timing of the flu shot is always going to be key. As I wrote last year, the best time for most of us to get flu shots is in November. The trend for the last few years (see picture below) is for flu season to begin sometime in December and taper off in March.

Thank you Ottawa Public Health for this excellent graph

BUT, the flu shot only starts to work two weeks after you get it, and its effectiveness starts to wear off after a couple of months. Timing is everything with the flu shot, and getting the shot in October is (for most of us) a bad choice. The shot will wear off before flu season is over.

Yet last year, my radio station/twitter feed/even Facebook page had numerous ads from Pharmacies advertising flu shot clinics in October (and buy your groceries at the same time!). This appeared to be driven by a desire to get a “customer” in the store soon rather than what was best from a health perspective (i.e. wait till November).

Additionally, there was all sorts of confusion around the high dose vs the standard dose flu shot last year. I wrote about this last year too. At the end of the day it does not matter which flu shot you get. Just get one! The effective difference between the high dose trivalent (three strain) flu shot and the regular dose three strain flu shot was 0.5%. This difference does not merit the hype around the high dose shot.

Furthermore, in Ontario we had a quadrivalent (four strain) regular strength flu shot. There was no study comparing the high dose three strain vs regular dose four strain shot that I could find. So really, there was no justification for the advertising from pharmacy ads that essentially said “high dose flu shots in stock, come quickly before we run out.”

This year, the choice of flu shots is going to be even more complicated. Have a look at a screen shot of an email I got from my local public health unit:

Six (!) different brands of flu shots covering a variety of strains (3 vs 4) and dosage strengths (high vs low). But again, to be clear, the difference between these are likely minimal. What’s far more important is that people actually get the shot (in November) rather than pick and choose and wait for one.

Yet if history repeats itself (and it seemingly always does), we can once again expect pharmaceutical chains advertising early in October that they have a “high dose” or “extra strength” or “added potency” or whatever shot, but you must book now! Hurry! Before they are all gone! And if you come real soon, you can even get 500 bonus points!

This level of consumer hucksterism has no place in health care. Health care decisions should be made based on evidence, appropriately done studies, and what’s in the best interests of the patient and society. They should not be made based on some marketing guru’s attempts to get people into a store (where conveniently they can get their milk and eggs too).

Most pharmacists I know are good and decent people who want to do what’s best for their patients. I actually applaud their willingness to give flu shots. The easier we can make it for everyone in society to get a flu shot, the better it is for all of us, and the less potential strain there will be on our health care system this winter.

But the corporate head offices that come up with these schemes (seriously, bonus points for get a flu shot??) need to think of what’s best for the health care needs of society first. That means NOT giving flu shots until November and NOT trying to promote one flu vaccine over another in an effort to create perceived demand and drive people to their stores.

Let’s see see if they act in the best interests of society, or in the best interests of their shareholders wallets this year.