Tone Deaf CFPC Fails Its Members, Embarrasses Itself

Recently, in what seems to these old eyes to be an insulting, vindictive and offensive move, Canadian Family Physician, the “Official Journal of The College of Family Physicians of Canada (CFPC)”, published a hit piece on Family Doctors that only serves to further demoralize and dishearten a beaten down profession. I cannot fathom the amount of, what at best could be described as political naïveté, and at worst a disconnected Ivory Tower mentality that would be required to write such a venomous attack on those who actually pay money to keep their organization going.

Seriously, what was the CFPC thinking when they okayed Roger Ladouceur’s editorial, titled “Family Medicine is not a Business.”?? (I refuse to link to it as I don’t want it to get any more hits).

Truly, it’s not really an editorial, rather a massive litany of complaints against family physicians, while sarcastically suggesting “surely, it’s just gossip!”

What exactly are evil rotten family doctors doing according to Ladouceur? He suggests the CFPC has “heard stories” about family doctors not seeing patients in person and wondering how they can assess complicated patients. He has “heard stories” about doctors only calling patients at more lucrative times and abandoning patients with high medical needs. He has “heard stories” about family doctors “charging excessive fees” for services not covered by health insurance.

He ends off his purulent missive by blithely stating, “Family Practice is not a business.” Marie (“Let them eat cake”) Antoinette would have been proud of such a comment, dismissively heaped on the approximately 40,000 overworked family doctors in Canada.

There’s a lot to unpack in Ladouceur’s diatribe. First and foremost is the fact that despite extolling the virtues of evidence based medicine, the CFPC allowed an editorial to run that had, well, no evidence to back it up. The whole argument was based on “I have heard stories.” There are no numbers to back it up, no names of offending physicians, no statistics on how widespread these alleged problems are. Just gossip and innuendo based on what he has “heard.”

If you want evidence by the way, I can confirm that the OMA Board was told that based on OHIP billing data over 98% of family doctors in Ontario continued to work after the pandemic was declared. It is true that they are using a mix of virtual and in person visits, but given the need to social distance during these times, a mix is clearly the correct way to proceed.

Furthermore, the banal statement that “Family Medicine is not a business” is simply factually incorrect, and reveals a kind of ignorant, Ivory Tower mentality that shows a complete disconnect from the real world.

Let me be clear about this, I consider myself one of the lucky ones. My family has food on the table. We have a roof over our head. There is no danger of my car being re-possessed. I’m fortunate compared to the average Canadian and am extremely grateful to be in that position.

But while I genuinely enjoy seeing my patients (they’re a great bunch of people), I still have to pay my staff, order supplies, pay rent and utilities, ensure my computers are working properly, get payroll taxes paid, comply with labour legislation etc etc. In short, while we all hate to think about this side of things, Family Medicine has been, and will continue to be a business of some sort. That the CFPC would allow such an obtuse comment by Ladouceur to run, shows a wanton disregard, and, dare I say it, contempt for the many day to day issues that its members face.

Look, no physician likes seeing one of their organizations scold them (and certainly I will always push back when I see this kind of stuff happening), but I really have to wonder just how completely out of touch the CFPC must be to allow this type of berating in the middle of the biggest physician burn out crisis I have ever seen. Prior to the pandemic, 26 % of physicians were clinically burnt out, 34% were suffering from a degree of depression and over 50% reported some symptoms of the burn out. Exactly what do you think has happened to those numbers after the pandemic? Especially with physicians recognizing that even though we seem to be coming out of the pandemic, there is an overwhelming backlog of delayed care to address?

Yet amongst this backdrop, here comes the CFPC, not to try to find ways to support physicians or provide tools to help them be healthy so they can look after their patients better, but to berate, admonish and vilify them as a group. This is supposed to make things better??

The type of evidence free invective Ladouceur ran should never have been given any platform, much less a platform on an organization who’s mission statement includes advocacy on the part of the specialty of Family Medicine. Frankly, I’m embarrassed to be a member of the CFPC, though given the regulatory requirements to maintain my continuing medical education, I can’t resign from it.

If the CFPC really wants to help, they will pull Ladouceur’s screed from their magazine, and apologize to all 40,000 Family Physicians in Canada. Anything less will suggest complicity and sympathy with his views, and will contribute to Family Physicians losing confidence in the CFPC.

Conscience Rights are HUMAN Rights

Last year, I wrote a blog about Conscience Rights.  The motivation for the blog was the concerning move by the Ontario courts to “infringe on doctors’ religious freedoms.

I know, I know, the case dealt with whether physicians (and other health care providers) had the ability to refuse to provide a referral for situations where they conscientiously objected. Currently, the hot topic for this scenario is Medical Assistance in Dying (MAiD). And yes, the headlines simply said the request for an appeal of a lower court decision on granting physicians conscience rights was denied. I also know there was a lot of talk about the right of the patient to determine their own health care (which is of course must be respected).

But in the text of the initial ruling, the courts clearly and unequivocally admitted that they were infringing on doctors’ rights.

I made a Star Trek reference in my last blog on this issue. Hence, one would be appropriate here. It would seem the Ontario Courts were using the logic first uttered by Mr. Spock in Star Trek 2 – The Wrath of Khan:

“Logic clearly dictates that the needs of the many outweigh the needs of the few.”

But is that really the case here? Will patients be unable to access legal health care services, simply because physicians are able to keep their fundamental human rights? The short answer is no.

In Ontario, for a service such as MAiD, all a patient really has to do is call the MAiD co-ordination service, and they are guaranteed an assessment. A physician who gets a request for this service simply has to give a patient the 1-800 number to call. Heck, patients can even look the number up online and call themselves without asking their own physician.

In short, the service is readily available to those who want it. The needs of the many are not, in any way, shape or form compromised by Conscience Rights legislation. The Ontario Courts have therefore willingly infringed on the rights of a minority, on the basis of a false premise.

Let me also mention the reaction to my last blog on this issue. I had mentioned that in the near future, we would be facing many ethical dilemmas as a society. Not the least of these include new genetic treatments and therapies. Most physicians were supportive of my blog but some expressed concern that brining up genetic advancements was too extreme. One commentator even used the analogy that seemingly all twitter arguments degrade to – “…can’t compare asking for MAID to asking to revisit the Nazi eugenics movement

And yet.

Look what’s happening in the world.

In China, a group of scientists have inserted human brain DNA into monkeys. They state the reason for this is to study conditions like Autism. Jeez, have these people never seen Planet of the Apes????

As Elon Musk dreams of colonizing Mars, scientists are now actively looking at “tweaking” the DNA of people who wish to colonize Mars as a way to protect them from harmful radiation and microgravity. There is even thought being given to merging our DNA with tardigrades (weird microscopic creatures that can seemingly survive anything).

This s all in addition to work that is being done by companies like Neuralink (another Elon Musk organization) to develop brain implants.

Indeed, as Davis Masci pointed out last September:

“But thanks to recent scientific developments in areas such as biotechnology, information technology and nanotechnology, humanity may be on the cusp of an enhancement revolution. In the next two or three decades, people may have the option to change themselves and their children in ways that, up to now, have existed largely in the minds of science fiction writers and creators of comic book superheroes”

These aren’t some weird tabloid, National Enquirer type stories. There are real scientists actively doing this kind of work. The point being that protecting Conscience Rights is not just about MAiD, it’s about ensuring that on a go forward basis, peoples fundamental freedoms are not impugned in what promises to be the most ethically challenging time for science in human history. It’s about ensuring that people do not have to work on or accept for themselves, things that they find morally objectionable.

As a free society, we have always recognized certain inalienable human rights. It’s not just the right to free speech, assembly or vote. The Canadian Charter of Rights and Freedoms specifically mentions freedom of conscience and religion (see section 2). This was due in large part to a recognition that a diverse society is a stronger society and in order to protect that diversity, we must protect fundamental freedoms.

That’s where the judges erred last year. By infringing on the rights of a few, stating that by doing so they were protecting the right of many (which as I’ve shown above, isn’t even the case), the judges have damaged our society as whole, and made it easier to take away more rights from more people. They failed to realize that you cannot make a society stronger, or more free, by taking away the rights of a minority. You only increase the possibility of taking away more rights in the future.

As a society, we must be ever watchful for these infringements on our freedoms. To use another Star Trek quote, this time from Captain Jean-Luc Picard (nerd alert – TNG episode “The Drumhead”):

Vigilance. That is the price we continually have to pay.

The REAL Reason NACI Recommends 16 Weeks Between COVID Vaccine Shots

Recently, the National Advisory Council on Immunizations, or NACI, announced that it was reasonable to wait up to sixteen weeks between your Covid-19 vaccination shots. This applies to the three, Health Canada approved, two shot vaccines (Pfizer/BioNtech, Moderna, and AstraZeneca). Canada is the only country in the world to stretch out the interval between shots to four months. The manufacturers of the vaccines continue to suggest three weeks between shots.

This decision was not without controversy. No less than Canada’s chief scientist, Dr. Mona Nemer, called this a “population level experiment.” Multiple other physicians have tweeted concerns about this. Pfizer/BioNtech won’t sign off on this, and I’m not aware of Moderna or AstraZeneca agreeing to this extended interval either.

But NACI is made up of some really smart people as well. They’ve been providing independent and unbiased advice on all vaccines to the Federal government since 1964. No doubt NACI looked at data from countries around the world, and found that in countries like the UK and Israel, the incidence of COVID19 fell dramatically in the general population after just one dose. This was particularly of note in the UK because they had delayed their second shot (to 12 weeks) despite being called reckless by other countries.

So, we have one group of extremely bright and knowledgeable people saying delaying the second shot up to 16 weeks is ok. Another group of extremely bright and knowledgeable people is saying that this is a problem.

Look, I’m just an old country doctor, not a virologist or immunologist or population health specialist or so on. There is no way I could get into an educated discussion about whether going to 16 weeks between shots will be safe and effective or not because my brain is just not big enough to understand all the minutiae around rising and falling antibody levels.

But I’ve been around long enough to have read multiple statements and press releases from bodies like this, and I’ve learned to read between the lines. Here’s what’s really going on, that nobody (including the press) is talking about.

It’s the fourth bullet point in the summary section of NACI’s recommendation:

  • NACI recommends that in the context of limited COVID-19 vaccine supply, jurisdictions should maximize the number of individuals benefiting from the first dose of vaccine by extending the interval for the second dose of vaccine up to four months

“The context of limited COVID-19 vaccine supply.” See the reason that NACI felt obliged to have Canada be the only country in the world that extends the interval to 16 weeks, is because Justin Trudeau and the Liberal government have botched the procurement of COVID-19 vaccines. If we had more COVID-19 vaccines, NACI would never have been put in a position of having to explore a population level experiment.

Trudeau has been saying for weeks now that more vaccines are coming. Heck back on Feb 19 he promised a “big lift” of vaccines. But despite all the hyperbole, the simple fact remains that as I write this blog, Canada is 62nd in the world when it comes to delivering COVID-19 vaccines to our population. We’re behind such illustrious world powers like Dominica, Serbia, Estonia and Aguilla to name a few. For a G-7 country, that’s just embarrassing.

Table courtesy of Our World in Data. Shows Canada has immunized only 8 people per 100 as of March 14, 2021)

This source for all the above information is Our World in Data and you can link to the relevant page here. It is updated daily so my comments are based on what I saw as of March 14, 2021.

Is it any wonder that there’s actually a #TrudeauVaccineFailure on Twitter?

Look, I, like you, am acutely aware that the Trudeau government has signed lots of deals with vaccine manufactures to get Canadians the vaccine. But it’s also extremely telling that Trudeau has refused to release the vaccine contracts. These contracts undoubtedly have a delivery schedule in them, so the fact Trudeau won’t let us see them really incriminates his government. It does nothing to dispel the concerns around the competence of how his government handled the vaccine procurement process.

Th main role of a national government is to protect the welfare of its citizens. If Canada had been in the top ten in vaccines procured per capita (surely not unreasonable for a G-7 country), NACI would not have needed to explore a 16 week vaccination interval. And we likely wouldn’t be looking at a third wave in Ontario.

By not procuring COVID-19 vaccines in a more timely manner, the Trudeau Liberals have failed the people of Canada.

Which COVID Vaccine Should You Get?

Me getting the first dose of my Covid-19 Vaccine.

Canada now has 4 different vaccines to help us fight COVID-19, BioNtech/Pfizer, Moderna, AstraZeneca and Johnson and Johnson. While that’s a (very) good thing, this has led to some inevitable questions about which vaccine is “better” and whether people should wait for one or the other. An email from a friend who questioned the AstraZeneca vaccine inspired me to write this.

First, to re-iterate once again, while is true that all of these vaccines were developed at a rapid pace, the reality is that they all have been thoroughly tested. The shortcuts that were made were made in the bureaucracy, not the human trials. You can read my thoughts on that here, or see my colleague Dr. Greg Rose explain it better here.

There will likely never, ever be a vaccine (of any kind) that is 100 per cent safe (ever), but overall these vaccines are extremely safe for the general population.

The difficult part in sorting out information about the COVID vaccines is two fold. First, there is a whole lot of information that comes out, almost on a daily basis. It’s hard for not just physicians to keep track of it all, but also members of the general public. Second, some of the information that is released is extremely premature, without a full analysis being done. First impressions being lasting impressions, this often times creates an incorrect perception of a vaccine, that is hard to refute later on.

For example, the BioNtech/Pfizer vaccine was initially plagued by concerns that it caused Bell’s palsy (based on a report that 4 people got it after taking the vaccine) and that death was a side effect (based on report in Norway of 33 people over the age of 80 dying after taking the vaccine). It wasn’t until later that a through review showed that the Bell’s palsy issue was actually the same or less than the background rate. Essentially, you would expect about 12 people a year in the vaccine group to get Bell’s palsy anyway, regardless of whether they got the vaccine or not, so the fact that 4 got it didn’t mean it was linked to the vaccine, just that they were going to get it anyway. As for the 33 deaths, turns out that was in keeping with Norways normal death rate for their population of over 80 year olds, so again, not related to the vaccine.

Think of it this way. The most common time to get a heart attack is actually three hours after you wake up. Does this mean eating breakfast causes a heart attack? Of course not. Just because those two things happen close together, doesn’t mean that one caused the other. In statistics this is referred to as “correlation does not imply causation.” Sadly, there is rather a lot of correlation that is brought up about all of these vaccines, and the assumption is made that they are causing problems.

It was initially claimed the Moderna vaccine had more side effects than the BioNtech/Pfizer one. But it was only after studying it more that people realized that these aren’t really side effects, but proof that the vaccine is working. Your second shot of the Moderna vaccine made your immune system mount a response to what it viewed as a foreign body. Thus the muscle aches, fever and headaches that went along with it.

Now most recently there is some sub-optimal information circulating around the AstraZeneca vaccine. First, there was concern that they would not work against certain strains of COVID19, particularly the South African strain. Second is concern about blood clots.

The South African strain issue was particularly overblown. “Only 10% effective” screamed out some headlines. South Africa even stopped using this vaccine as a result. The full story is somewhat different.

Turns out the study that suggested AstraZeneca wouldn’t work against the SouthAfrica variant was very small (2,000 people), and not well done. Further more, what really matters, is preventing deaths, hospitalizations and severe disease and AstraZeneca works for this with the South African strain. Perhaps you may get a mild case of COVID19 (cough, fever, mild muscle aches for a couple of days). But the point of the vaccine is prevention of severe cases and deaths.

Similarly, the blood clot issue again appears to be one of correlation, not causation. The background rate of blood clots in the population would explain the ones found in Europe. Health Canada and Thrombosis Canada is not worried, and you shouldn’t worry either.

So back to the question at hand. Which vaccine should you get? My personal feeling is the J&J one would be the best simply because, logistically it’s much easier. Get one shot and it’s done. The problem with that one is that we have an effete Prime Minister who’s totally botched vaccine procurement for Canadians. There’s a reason #trudeauvaccinefailure is on twitter. Last I checked we are 61st in the world for procurement of vaccines (and for a G-7 country, that’s just embarrassing).

While happily announcing the approval of the J&J vaccine, Trudeau and the Liberals neglected to emphasize the fine print. Namely that the vaccine would likely not start to arrive until the end of April or early May, and that would only be in small amounts. The bulk of this vaccine won’t be in Canada until September.

Of course, right on queue, a few days after boasting about J&J, it was announced there would be production delays. Why the media isn’t talking about the outright incompetence of Trudeau and his government in protecting Canadian lives is beyond me.

Therefore, the best thing you can do is get the first vaccine that you are offered. When you get notified to get your shot, don’t ask which one, just get it. For what matters the most (keeping you out of hospital or dying from COVID19), they all work roughly the same.

I urge you all to do your part, protect yourself, protect others, and let’s get ourselves out of this pandemic, and back to a normal life.

A Great Cause.

As an addendum I would like to encourage all of my readers to consider buying some merchandise from Conquer Covid 19. This all volunteer group did yeoman’s work providing PPE to physicians, health care workers and others in need. Last year they raised $2.4 million and donated around 3 million (!) pieces of PPE.

This year they are selling their extremely boring merchandise (check Ryan Reynolds take on it here) and proceeds will go to LTCfrontline foods, providing hot meals to those workers who are struggling in long term care homes and Call Auntie, an organization that helps Indigenous people navigate issues around COVID19.

Please click here and donate what you can.

HEPA Filters, Focus on Ventilation Can Help Open Economy

This week, much of Ontario moves out of a complete lockdown (I finally get a hair cut!). The move itself has not been without controversy, with some critics saying the government is opening too fast, and others saying they’re opening too slowly.

There is no doubt in my mind that if we can re-open the economy safely, we should. COVID19 has done terrible damage over the past year. Lives lost. Families unable to say goodbye to their loved ones. On going health issues in those who survived COVID19 infections and much, much more. But there is also an increase in the number of people suffering from mental illness, a rise in domestic abuse, and very real economic hardships faced by millions of Canadians.

It has been noted that there were were more deaths than expected in Canada last year, and not all of these “excess deaths” were directly caused by COVID19. We are starting to realize that some of deaths are “indirect”. That’s to say, the social isolation, the lack of emotional, financial and other support, the delayed medical procedures and more, have caused these deaths.

This situation is particularly bad in British Columbia and Alberta, where there were 270 and 360 more deaths than expected between March 15 and April 25 alone, and these were not directly attributed to COVID19.

To be clear, the lockdowns were necessary. And if we open the economy in an un-safe manner, COVID cases will rise again, there will be more death and perhaps even a dreaded third wave. We’ve seen from Sweden what happens when a country doesn’t shut down in the face of COVID. Even their king has admitted Sweden’s approach was a total failure.

It’s just that we cannot ignore the pain and suffering that occurs by a lockdown as well.

That’s why to my mind the focus needs to be on how to re-open safely. We have one of the worst pandemic responses in the world, so we must do better. Is there something we can do, that hasn’t been done in Canada yet?

Turns out, there just might be.

For far too long, Health Canada did not focus on airborne spread of COVID19. They stressed the “droplet” method of transmission, where fluid particles are expelled from your mouth, land on a surface and are then when you touch them, wind up on your fingers, and then into your body when you touch your eyes, nose or mouth. Full disclosure, if you search hard enough, you can find a video of me somewhere on the net saying exactly that, and telling people not to wear masks. It is clearly outdated now, and should be ignored.

Japan, by contrast, focused on airborne spread as far back as February of 2020. Their whole focus was to ensure proper ventilation and using air purifiers with HEPA (High Efficiency Particulate Air) filters in rooms. Everybody was asked to wear a mask early last year. Granted it is culturally more accepted to wear masks in Japan. But the focus was on airborne spread right from the start.

A diagram showing Japan’s process for dealing with COVID19, part of their submission to “Environment International” – September 2020 edition

How well did Japan do? Japan has a population of 125 million people in a country about 3/4 the size of Baffin Island. As I write this, data from their COVID tracking system shows that 417,116 people have been infected (0.33% of the population) and 7,038 have died (.0056% of the population).

These numbers are all the more remarkable considering that Japan did just about everything else wrong. They did not test enough (at least at the beginning), the lockdown measures were half hearted and voluntary, many pachinko parlours (a mix of gambling and alcohol) stayed open, and traffic on their notoriously crowded commuter trains to work was only down 18%.

Health Canada did not even acknowledge airborne spread of COVID19 until November 2020 (9 months after Japan and 4 months after the World Health Organization). Our Covid19 tracker shows terrible results. We have a population of 38 million. Yet as I write this, we have had 826,528 cases (2.17 % of the population or 6.6 x as many as Japan on a pro-rated basis) and 21,309 deaths (.056% of the population or almost exactly 10 x as many deaths as Japan on a pro-rated basis).

It does make one wonder, if we had approached COVID19 as having airborne spread right from the start, could we have saved a number of lives, and limited the lockdowns we endured? And now that the evidence is strong that COVID19 is airborne, should we not have businesses focus on safe ventilation as a condition for opening?

What’s required for optimal ventilation? Well ideally, you should have an HVAC system that exchanges the air in a given room 6 times an hour with an HEPA filter. HEPA filters can remove the vast majority of droplets that the COVID19 virus (and other viruses!) live in. But the reality is that this would be ultra costly and take far too long to replace every HVAC in most commercial buildings. (Should definitely be a requirement for new commercial properties and especially the new nursing homes Ontario is building).


What can other businesses do instead? One of my patients is a manager at a Tim Hortons. They have 14 tables at the Tim’s. What if the restaurant put a portable air purifier with a HEPA filter on each table? There are many brands that cost $80-$100 each for a small size one. But with one on each table (where people would be talking and eating without masks, thus expelling the virus), you could reduce viral spread.

Granted at that price, the air purifiers would only last about six months, but by that time hopefully we will all be vaccinated anyway.

Similarly, we could mandate appropriate air purifiers in other businesses as requirement for opening. To be clear, people should still wear masks, wash hands regularly and physically distance as much as possible. Those are important and necessary precautions for re-opening. But the HEPA filter purifiers would simply provide that extra level of protection. It’s why I asked my nursing home to install them in their facility (and thank you to the owners of Bay Haven for doing that).

Canadians have suffered terribly over the past year. For the sake of our physical and mental health we need to re-open the economy, but do it in away that will not increase COVID19 infections, and not have us yo-yo between lockdowns and re-opening. Focusing on ventilation and HEPA filters can help us do this safely.

COVID19 Has Exposed Flaws In Our Public Health System

“Be hard on the problem, not on the people.” – unnamed OMA Executive

When I was President of the Ontario Medical Association (OMA), I had the privilege of touring the province. The tour was during flu shot season, so I took the opportunity to meet many Public Health physicians and staff. They are all good, hard working people who are dedicated to their communities and doing their best to advocate for the health care needs of the population.

Unfortunately, the Public Health system in Ontario (and Canada) is fragmented and disjointed. This really impeded the ability of Public Health to act in a unified manor prior to the pandemic. But because Public Health wasn’t as “visible” at the time, the flaws in the system remained hidden.

To understand just how this fragmentation affected our health, one only looks at the situation around trans fats. I wrote about this previously, but in short:

– We’ve known since 1993 that trans fats are linked to increased heart disease

– We’ve known since 1995 that Canadians are one of the highest consumers of trans fats in the world

– Denmark, led by their strong public health system, essentially banned trans fats in 2004 and within 2 years had 4% less deaths from heart disease. There was also a reduction in childhood and adolescent obesity.

– The results were so good that many other European countries followed suit.

If we apply the Denmark results to Canada, we could prevent 600 heart attacks a year. Banning trans fats would seem to be a no-brainer, and clearly the type of thing Public Health should effectively advocate for.

But here in Ontario, outside of the City of Toronto trying to ban trans fats in restaurants in 2007 not much has been done about this. Part of this is because Ontario has 35 different Public Health units, who all function independently. They may not even have the same software when collecting data, and some still use paper charts. Because they all function independently, just because Toronto Public Health wants a ban, doesn’t mean all the other units would even know about it, much less share information on it, or advocate for it. And of course, every Province and Territory has their own autonomous Public Health System.

So essentially, the Public Health Units were unable to co-ordinate around this issue, and outside of trying to ban Trans Fats in school cafeterias, and a failed voluntary guideline by Health Canada, not much has happened.

It wasn’t even until 2017 that Health Canada got around to proposing a ban on trans fats, and 4 years later this still hasn’t happened. It’s worthwhile noting that over 10,000 heart attacks could have been prevented if we had acted at the same time as Denmark.

If in “normal”, non-pandemic times, the Public Health system was so fragmented, and disjointed, that something this straightforward couldn’t be accomplished, how would they perform in a once in century pandemic?

The answer, sadly, is not very well.

Just as the various Public Health Units couldn’t co-ordinate on the same message for Trans Fats, it appears the various units can’t co-ordinate on the same messaging around COVID. Case in point, on Nov 4, 2020, Health Canada finally (!) announced that yes, indeed, the coronavirus has airborne spread, and all facilities should take airborne precautions.

Dr. Theresa Tam, Chief Public Health Office of Canada announcing COVID19 was, indeed spread by aerosols

Yet a look at the website for my Public Health unit (Simcoe Muskoka) on Jan 10, 2021 (2.5 months later!) still shows the same guidelines that’s before the announcement. Namely, that the virus is spread through droplets and so cleaning surfaces is more important.

From Simcoe Muskoka Public Health, Jan 10, 2021.

So here we have two different messages coming from public health authorities.

By comparison, take a look at Japan. Japan decided back in February 2020 that the virus was aerosolized. They too have many regional public health offices, however, the regional branches send the information to the national office, and the national office makes decisions. Those decisions are clearly communicated to the public, so the same message goes through the country.

They very quickly focused on things such as air purifiers with HEPA filters in rooms, improving ventilation by leaving windows open (even in the crowded community trains) mask wearing, and improved HVAC systems.

A diagram showing Japan’s process for dealing with COVID19, part of their submission to “Environment International” – September 2020 edition.

As a result, on a per capita basis, Japan has only 1/8th the number of infections, and 1/14th the number of deaths from COVID19 as we’ve had in Canada so far.

But it’s not just messaging that’s the problem. Public Health Units are hampered by their archaic systems from adequately preforming the test/trace/isolate process so important to controlling the spread of COVID19.

My practice is close to the border of the Simcoe Muskoka District Health and the Grey Bruce Health Unit. If one of my patients comes down with a reportable illness, I have to figure out which health unit to report to. But they use separate forms. Additionally because they use separate data systems, they can’t share information between the two.

Supposing one of my patients were test to positive for COVID-19. What if they live in Grey Bruce, but work in Simcoe Muskoka. Who should I report this to? And more importantly who is responsible for the contact tracing considering they work in one area and live in another? Especially since they can’t share data.

The result? Effective test/trace/isolate does not occur in Canada.

Compare this to South Korea. South Korea has multiple regional offices for public health, but they’re integrated by the Korean Ministry of Health and Welfare (KMHW). They share software, and so can share data and information.

By having all of Public Health integrated, South Korea was able to have one source for information. So not only did they have a consistent message (the KMHW gave two press conferences a day), but they were able to effectively test/trace/isolate.

On a per capita basis, South Korea has only had 1/13th the number of COVID cases as Canada, and 1/20th the number of deaths.

Canada’s response to the COVID pandemic is among the worst in the world. Only the fact that we are next door to a country that has had arguably the worst response in the world seems to prevent Canadians from recognizing this fact. If there is one learning that me must take forward from this, it is that lack of an integrated, seamless and co-ordinated Public Health system has cost us many lives.

As a country, we need to support the people working in Public Health by improving the systems they have, so they can protect us in the future.

Note: This blog is based on the first part of a presentation I gave to the Public Health Youth Association of Canada (my thanks to them for asking me to speak). If you are suffering from insomnia, or if you are generally good person and want to support young people who are keen to improve the world, feel free to watch the presentation here:

Open Letter to all Residents of the Georgian Bay Region

The following letter was sent to local media outlets by the Medical Staff of the Collingwood General and Marine Hospital. It has been re-produced here with permission.

To All Residents of Georgian Bay:

A day that we had hoped would never come has sadly arrived.  A concerning rate of COVID19 has been demonstrated in our community and has been reflected in recent hospital admissions, as high as almost 10 per cent of all patients in Collingwood Hospital this past weekend.  The surge in patients hits us at a time when all of us would normally be planning Christmas dinners, trips with friends and family, and looking forward to well deserved vacation time.

As your physicians we have volunteered much of our time preparing for a day like this all the while hoping it wouldn’t come.  We have helped to set up our Covid Assessment Centre.  We have ensured that the hospital continues to have physician coverage and that Emergency care remains unchanged.  We have helped set up drive through flu shot clinics.  We have helped set up an Alternate Health Facility to offload the Collingwood Hospital.  We have attended many extra meetings outside of our normal clinical time.  We have kept local Family Physician offices and the After Hours Clinic open for both virtual and in-person visits. Our Hospital remains open for emergencies as well as routine, scheduled care. 

But now we need your help.

If all of us don’t take necessary precautions to protect our community our hospital is in danger of being overwhelmed, and we may not humanly be able to take care of a large influx of patients.

So we ask all of you:

– Please shop locally but wear a mask in stores, and at all public places

-Please maintain physical distancing of two metres (or one moose length)

-Please stay in your own social bubble of 10 people

-Please ask your friends and family not to come visit you this year

-Please stay home and do not travel to other areas

What we ask of you is difficult.  These asks come at a time of year when social events are the norm.  A time of year when many of us attend celebrations and a time of year when we normally enjoy fellowship with others.

But historically, it is also a time of year when our sense of community and our love for our fellow citizens, has always shone through.  This year, there is no better way of showing our commitment to our community by following the asks we have of you.  In this way, you will show that you care enough about our community to keep it safe and healthy.

We promise to continue to do our part to provide the best possible care to you.  We ask that you help us, help you and those you love.

Yours truly,

Gregg Bolton,

President, Collingwood General and Marine Hospital Medical Staff

Does Bill C-7 Make Assisted Death the Path of Least Resistance?

The following blog was co-written with me by Dr. Leonie Herx, Division Chair and Associate Professor of Medicine at Queen’s University and Past- President of the Canadian Society of Palliative Care Physicians and Dr. Ramona Coelho, a family physician who provides care to a large number of marginalized patients. A version of this opinion piece initially ran in the London Free Press on Saturday December 5, 2020.

As the COVID-19 pandemic dominates the political agenda and strains the country’s health-care systems, the federal Liberals are intent on passing Bill C-7, which proposes to expand medical assistance in dying (MAiD) to those who are not dying. Proponents of the bill state that it allows choice and dignity for those with chronic illness.  However, the bill fails to provide them with the dignity and humanity of requiring them to have good care or access to supports.

As physicians, we witness the struggles that confront our patients and their loved ones every day. Those living on the margins and with disabilities face significant barriers to care though systemic discrimination (ableism) that can make it harder to live a healthy, fulfilling life in community. As doctors we should be instilling hope, supporting resilience and using our expertise to find creative solutions to address health and wellbeing. Instead, we now will be required to suggest assisted suicide as an option.

Spring Hawes, a lady who has a spinal cord injury for 15 years publicly stated, 

“As disabled people, we are conditioned to view ourselves as burdensome. We are taught to apologize for our existence, and to be grateful for the tolerance of those around us. We are often shown that our lives are worth less than nondisabled lives. Our lives and our survival depend on our agreeableness.” 

A choice to die isn’t a free choice when life depends on good behaviours and compliance to societal norms. Sadly, the medical community can be complicit in this messaging.

Gabrielle Peters, a brilliant writer, who has struggled with poverty since her disability, has shared that a healthcare professional sat at her bedside and urged her to consider death. This was just after Gabrielle’s partner announced he was leaving her because she was too much of a burden and she no longer fit into the life he wanted. 

Doctors can pressure someone to die as in Gabrielle’s situation but also more subtly can confirm a patient’s fears that her life is not worth living and MAiD would indeed be a good medical choice.

Day after day, we participate in a healthcare system and a social support system that does not come close to meeting the basic needs of our most vulnerable patients. However, our role as physicians should always be to first advocate that our patients access all reasonable supports for a meaningful life with no suffering.  But alas, Canada does not seem to prioritize health care and supports for all, and soon, that lack of support will be pitted against an option to access death in 90 days.

Patients entrust doctors to make ethical decisions every day regarding their care and to make recommendations that are always aimed at promoting health and healing. The core role of medicine is to be restorative, not destructive. Advocating for our patient’s health and wellbeing, is a solemn oath we took.

As physicians we help our patients do many things in the context of a trusting, shared, decision making process. Doctors encourage healthy habits.  We refuse to prescribe antibiotics when patients have a viral infection, or opioids on demand. We pull a driver’s license when we have concerns for patient safety and the public good. We refuse to write mask exemptions without good reason. We serve both patient and the common good.

All of this requires courage to not betray the trust society and the patient has bestowed on our profession. Society’s belief in the inherent virtue and ethics of the profession has been the necessary basis of the physician-patient trust.  Would you trust your doctor if you thought they didn’t care about your safety and well-being?

While we recognize patients have the right to ask for MAiD, physicians must not be forced to suggest or forced to facilitate this, when reasonable options for living with dignity exist. We must continue to offer our patients what is good and practice medicine with integrity.

As Dr. Thomas Fung, Physician Lead for Siksika Nation stated, 

“Assisted death should be an option of last resort, and not the path of least resistance for the vulnerable and disadvantaged. Conscience protection is needed in this bill, as no one should be forced to participate in the intentional death of another person against their good will.”

One of the most important foundations of our Canadian identity is that we are a caring, compassionate country. We are proud of our universal healthcare mandate, and we place a high premium on being inclusive and tolerant while working hard toward the accommodation and integration of marginalized and vulnerable members of our community. And yet, if Bill C7 is allowed to stand without amendments, we will be in serious danger of losing this fundamental element of our Canadian identity.

Get Your Flu Shot…..in NOVEMBER

Every year in my office, usually just after Labour Day, the influx of phone calls begins. It’s always the same question -“When are you giving the flu shots?” While it’s easy to grumble about the increase in calls, the reality is that patients who are calling are being pro-active about their health. This is to be lauded as pro-active patients often have the best health outcomes.

Above image from St. Patricks Home of Ottawa.

This year the phone calls came earlier than ever. There’s a general sense in my practice that more people want the flu shot (a good thing) as patients are concerned about winding up in hospital, and contracting COVID19 while there. The fear of a “double threat” in hospitals is high, and I suspect that more people will get a flu shot this year because of this same fear.

This is also compounded by some erroneous information out there about what the flu is. A lot of people who have a cough, or the sniffles or a low grade fever think they have “a touch of the flu.” That’s not really the case. If you have a cold, you will have a fever, cough, and runny nose, but you will not feel like you’re on death’s doorstep.

If you have the flu, in addition to those three symptoms, you will feel like you got run over by a truck twice. The second time because the flu virus will have wanted to to ensure you really really felt it’s presence. Muscles you never knew existed will hurt for days, and it will be an experience you won’t soon forget.

So a lot of people who are getting a cold are concerned that the flu season is already starting. It’s not.

According to Canada Flu Watch, as of October 4, there is an exceptionally low level of flu activity across Canada. The percentage of positive flu tests is a mere .05%, which is well below normal. The flu is not in Canada (yet). I think most physicians would agree that an emphasis on social distancing, hand washing and mask wearing has had a large roll to play in this. Those three things don’t just reduce the spread of COVID19, they also reduce the spread of other viruses, including the flu.

Usually flu season begins around the first week of November with a few cases, peaks in January, is of concern until the end of March, and occasionally drags on into May (see below).

Graph is from the excellent Ottawa Public Health website

However, since the flu numbers are so low this year, it is likely that our flu season will be delayed somewhat. It appears that we can wait just a little bit longer to get it this year (but you should get it)!

The trick with getting the flu shot is timing. It takes your body about two weeks to build up full immunity after getting the flu shot. But, after about 28 days, the immunity starts to wane, slowly perhaps, but it does wane. (Medical nerds out there may want to read this study). Getting the flu shot too soon, means it may wear off before the season ends.

This year, what would be the best thing to do?

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

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

Third, for most other people in the community, the first couple or three weeks of November are likely the ideal time to get the flu shot this year. My own office won’t even be having our flu shot clinics until November (my patients will get emailed once we firm up the logistics). This is being done to ensure that we all have a reasonable amount of immunity until the end of the flu season.

So let’s all do our part. Continue to social distance, wear a mask, wash your hands frequently (for 20 seconds) and get a flu shot in November. Together, we can ensure that the the double threat remains a threat, and not a reality.

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

Integrated Health Care: If Not Now, When?

As always, opinions in the following blog are mine, and not necessarily those of the Ontario Medical Association.

Recently, Canada Health Infoway, a non-profit organization funded by the federal government to develop digital health solutions, announced that their electronic prescription solution, PrescribeIT, was adopted by the Shoppers Drug Mart and Loblaw chain of pharmacies. This followed on the heels of PrescibeIT being accepted by the Rexall chain. PrescribeIT allows physicians to essentially send electronic prescriptions from their Electronic Medical Records (EMRs) to pharmacies directly, eliminating the need for paper prescriptions.

Reaction from many physician leaders was generally positive:

Other reports indicate how solutions like this have helped during the current COVID19 pandemic. In England for example, 85% of prescriptions are now electronic, thus helping with social distancing.

While I’m glad progress is (finally) being made, I’m forced to ask one question. Why did it take so bloody long?

As I’ve mentioned repeatedly to various health care bureaucrats over the years, my region (Georgian Bay) has had electronic prescriptions for ELEVEN YEARS now. We’ve regularly been emailing pharmacies and had them message us with either requests, or further information.

Our project additionally allows for pharmacists to become part of the health care team by allowing them limited access to a few important pieces of health information they need to do their job properly. For example, they are allowed access to the patients kidney function tests (knowing that many drugs are excreted by the kidney). In that way, I have gotten much advice about changing the dosage of medicine based on how someone’s kidneys are working.

Building on this project, our local area has also ensured that the our After Hours Clinic uses the local EMR, so if patients have to go there, the physician on call can easily access their charts. The local hospital allows us to house our server in their IT room (increases security because of all the firewalls). The advantage of this is that hospital physicians can access all the outpatient records if needed, and provide better care for patients. Even our local hospice has access to this so that patients can get the care they deserve during their last days.

We were even able, for a three years to have the nursing homes access and securely message our EMRs. The result was an over 50% reduction in admissions to hospital from the nursing homes. The cost of the project was $35,000 per year, but the government couldn’t find the right pocket of money to fund it (sigh – see here for how the bureaucracy works) and so the project died. If you need a cure for insomnia, my talk with more details of how the project worked is here (skip to 7:28):

This then is the real frustration that I, and many other physicians have with EMRs and other Health IT systems. Can you just imagine how much further we would be if all areas of the Province had what a few isolated regions (like mine) have?

For COVID19 for example, our Covid Assessment Centre is on our EMR which means that I get an automatic notification if someone goes for a test. And if that test is positive, it allows for quick notification of the family physician so we can begin the process of contact tracing. It also allows for easy transmission of information of people with febrile respiratory illnesses so that we can track important information like when the symptoms started and ended.

Dr. Irfan Dhalla wrote an exceptional piece in the Globe and Mail on preparing for the winter in times of COVID19. Unsurprisingly, he called for reducing “untraced spread” of COVID19 (50% of all cases have no known contact) and a large part of that solution is a technological one, namely the Canada COVID alert app (available at both the Apple App Store and the Google Play Store).

While he’s correct about that, the reality is that we have more illnesses that we have to deal with than just COVID19. We need to be able to manage cancer, other infectious disease, heart disease, diabetes, the frail elderly with multiple problems and much more. The better we manage those illnesses, the more we can keep those patients out of hospital, which is great anytime, but particularly when there is a risk of hospitals being overwhelmed by a pandemic.

Again, in our neck of the woods the Home Care case co-ordinators are on our system. I often get messages from them about how one of my patients is doing, and requests for information from them (so much easier than faxing). This allows me to remotely address concerns patients are having sooner, and for frail patients, getting treatments sooner can often prevent a rapid deterioration, which will of course, prevent a hospitalization.

So while I really am glad that many more physicians will have access to PrescibeIT, I reluctantly point out that in its current iteration it only does about 65% of what our solution does. I suppose that’s better than 0% which people had before, but it is a testament to the failure of a wide swath of health care bureaucrats over the years that this is the best we have.

Even our system is not perfect. I get miserable situations like some of my COVID19 results come in through OLIS (Ontario Lab Information System) and others through HRM (Hospital Report Manager) and yet others get faxed (!) to me. The auto-categorization in HRM is really a complete joke. I dictated a note on one of my hospital inpatients, and the system classified me as a combined General Surgeon, Anaesthetist and Paediatrician – and while I’m glad the system thought I was that smart, the reality is I now have to go through all this data and spend extra time categorizing it properly.

eHealth Ontario, Ontario MD, Health Quality Ontario, the Ministry of Health and its various digital health teams were all to work co-operatively to build a strong Health Information System. But the reality is that these individual systems do not share information in a way that benefits patients.  The shared vision for health IT in the province (integrated health systems IT) still only exist in pockets around the province. There are lessons to be learned here and steps that should be taken.  All of which would really be beneficial now as we head into a potential second wave of COVID19.

Which leads this old country doctor to wonder: If knowing that a potentially huge crisis is coming our way in health care, will no one step up with a vision to fix Health IT Systems and Integrate Health Care information once and for all? And if not now, WHEN?