Canada – Page 2 – justanoldcountrydoctor

Dr. Soni Writes to her MP About the Recent Tax Law Changes

My thanks to guest blogger Dr. Deepa Soni, an Emergency Room Physician at Credit Valley Hospital. She has written a much more eloquent letter to her MP about the recent tax changes introduced by the federal government, and allowed me to reproduce here as an open letter.

The Honourable Anita Anand,

MP, Oakville,

301 Robinson Street

Oakville, ON

L6J 1G7

April 20, 2024

Dear Minister Anand,

I’m writing to you as a constituent of your riding in Oakville regarding your government’s capital gains taxation measures introduced in this week’s budget.

As an emergency physician for the last 25 years, I and thousands of my colleagues in Ontario, were saving in our medical corporation to be able to fund benefits that many Canadians have available through their jobs: maternity leave, disability, and medical/dental benefits. In addition, and most importantly, incorporation allows us to save for our retirement as we do not have pensions (again, a benefit many Canadians, including government employees and civil servants have as part of their employment). Incorporation was a negotiated benefit that was given by the provincial government in lieu of increasing our fees, with the understanding that the structure would allow us to mitigate some of these factors about our career.

Anita Anand, President of Treasury Board

When planning for retirement under one set of assumptions, and then finding out that the federal government has moved the goal posts to extract revenue for its budget shortfall, you can understand why so many physicians are bewildered and disappointed by the Liberal government. This would be the equivalent of someone changing the terms of your pension or taking large chunks of it away. For many doctors, this will have profound impacts on their ability to retire when they thought they would.

In addition, as a daughter of first-generation immigrant parents, both of whom were physicians, I am certain you had a front row seat watching your parents work hard to obtain their medical degree, residency, and then establishing a practice. This is not to say that other Canadians don’t work hard: the one thing that makes doctors unique is that our fees are set by provincial governments and our fees have not risen to keep up with inflation. Unlike other incorporated professionals such as accountants, dentists, and skilled trades, physicians cannot increase their fees to make up for rising costs. We are locked into the fee schedule determined by provincial governments (who are always employing cost containing measures to balance budgets). The federal government is turning a blind eye to this important point as it does not fall under federal jurisdiction. Nevertheless, the impact cannot be ignored.

As a corporate lawyer prior to being elected an MP, I’m sure you would not have wanted your hard work and education to be characterized with the words ‘tax cheat‘ if you had been using a legal way to save for retirement. This is the narrative being circulated in the media and it is deeply disappointing. It is noteworthy that MPs receive an annual pay raise (this year ranging $8000-11900), along with pension and benefits. This makes an MP salary one of the highest earners in Canada, with guaranteed income through retirement.

Yet, it is doctors who are singled out as being in the wealthiest 1% and rhetoric implying that we are not doing our part for less fortunate Canadians. We pay into personal taxes and contribute to the economy like everyone else. As small businesses, doctors support the economy through employing staff (nurses, allied health, receptionists etc.), paying rent, and financially supporting many Canadian companies providing support services to our practices (electronic medical records, medical office supplies etc.).

We are also entrusted with caring for the population of Canada in the most sacred way. This taxation measure comes at a time when the medical profession in Canada is suffering unprecedented levels of burnout. Millions of Canadians cannot access a family doctor because they have closed their practises and left (in large part, due to rising costs and fixed fee schedules). Why in an era when attracting medical graduates to do family medicine is a priority, would your government eliminate one of the few advantages that help new grads set up comprehensive practices so they can care for Canadians from cradle to grave? Does your government understand the downstream effect this capital gains taxation will have on patients for decades to come?

From watching media interviews recently, it appears that the federal government’s solution to this is “we will just allow in more foreign doctors“. This is deeply hurtful on many levels: it devalues currently practising physicians who have put in their life’s work to bring excellent care to this country’s patients. In addition, it takes many years for a doctor to acclimatize to the healthcare system in Canada. What happens to patients in the meantime? The solution is not to “throw the baby out with the bathwater”. The solution is to step back and really take in the impact of these actions and the message that has been conveyed to the physicians of this country. I hope your government will rethink this and choose to act fairly regarding incorporation for medical professionals.

Sincerely

Deepa Soni MD CCFP(EM)

Exploring Medical Tourism? Here’s What to Consider.

Full disclosure: I am a consultant for Medicte, a medical tourism firm that provides high quality, cost-effective medical treatments for ALL health conditions in Turkiye. Contact: info@medicte.ca for more information.

Recently, former Ontario Medical Association (OMA) President Dr. Shawn Whatley wrote an opinion piece in the National Post (later reproduced in the Medical Post) quite correctly rebuking Federal Health Minister Mark Holland for insulting people who consider leaving Canada for medically necessary health care. According to an Ipsos Reid poll, that’s 42 percent of all Canadians. As Dr. Whatley pointed out, this isn’t exactly a new phenomenon. In 2017, well before the Covid pandemic that people like to blame for just about everything, over 217,000 Canadians left the country for medical care. God only knows the 2023 number, but it will most certainly be higher.

Ironically enough, the day after Dr. Whatley’s piece was reproduced in the Medical Post, the Medical Post sent me their daily email which included a link to an article that showed Canadians are waiting even longer for surgical procedures than they were in 2019, and it’s not like the 2019 numbers were any good to begin with. It’s well known that increased wait times result in worsening morbidity and mortality (i.e. the longer you wait, the sicker you become). So it’s no wonder that Canadians are exploring ways to get treatments quickly, even if they have to pay out of pocket. Heck, I’m already on record as saying that I will go to Turkiye if Allah/God/Yahweh forbid I got a serious medical illness.

If you too are exploring medical tourism, here’s a list of things to consider.

How safe is the country I’m going to?

The sad reality is that the world has turned decidedly ugly these past few years. Picking a safe country can be hard. Stories like the one about Americans who went to Mexico for medical tourism and got shot by drug cartels get widely publicized. But there are many unsafe countries in the world. If I was looking at south of the United States, I’d probably limit my choices to Costa Rica and Cayman Islands. There are simply too many economic, political and frankly criminal elements in the rest of the countries south of the U.S.

Even in different continents you have to look at safety first. About 5 years ago a patient of mine of Ukrainian descent went back to Ukraine for a procedure. Obviously would not suggest that now with the war on. So look for somewhere stable.

What is the quality of the hospital I will get treatments at?

No hospital is perfect. But you should at least ensure that the hospital you are going to get care at is accredited by the Joint Commission International (JCI). They are the leading international organization that accredits hospitals and other health care organizations in 70 countries across the world. JCI Accreditation won’t guarantee a successful treatment, but it comes with the assurance that you will be getting appropriate health care.

After ensuring JCI accreditation at the facility you are looking at, then check for references. See if you can talk to people who got care there for their first hand experience.

Get a video consult first.

It’s the 21st century people. Video calls are a thing. If the health care organization you are looking doesn’t offer you the ability to have a video consultation with their doctors, before flying out to their country, well that’s a bad sign. During the consultation, ask lots of questions. Specifically ask about their complication rates and what is covered if you are unfortunate enough to get one. Get a “feel” for the doctor. It’s a big decision, be 100 per cent comfortable that the health care organization you are considering, will be able to take care of your needs.

What’s the Cost?

Obviously, at the end of the day, you are going to have to pay for your treatment. I would, of course, not suggest getting the cheapest possible treatment – because that institution has likely cut a lot of corners to get the price down. But at the same time, I weep for the lady from British Columbia, who, frustrated with the long wait times to see an oncologist, spent over $200,000 (US) on cancer care in the United States. She could have gotten the same treatments for around $70-80K in Turkiye. That’s obviously a lot of money, but still a significant savings.

This is actually why I would recommend you NOT go to the United States for medical tourism. Firstly, they have quite a bit of variability in terms of the care they provide. Some facilities are really good and others……well, some are really good. Secondly, the cost just isn’t worth it. A joint replacement that costs $50,000 US in the United States, could likely be had for $15-$20,000 US in another country.

If you are on a budget, or if you, like many others, are going to take out a loan or dip into your retirement savings to pay for these treatments, that difference is significant.

In Conclusion

While some provinces are making necessary investments in health care, the reality is that improvement in wait times are likely years away. The Canadian public is not stupid, they know this. Only 17% of Canadians feel the health system will improve in the near term.

In the interim, I fully expect the number of Canadian citizens who opt for medical tourism to increase. This can be a safe and effective option for Canadians willing to explore this route, but it is important to do your homework first.

A Message for Medical Students Who Didn’t Match on CaRMS Day

The following blog was written by Dr. Darren Cargill (pictured inset) and originally appeared in the Medical Post in a modified form and it’s full form on his substack. It’s a great message for medical students who didn’t match on CaRMS day, and is being re-printed here with Dr. Cargill’s permission (and my thanks) so that it is more widely available in an un-gated site.

J.J. McCarthy and the UnMatchable

“Those Who Stay Will Be Champions”

On November 14, 2020, Michigan was blown out by Big Ten rival Wisconsin by a score of 49-11, dropping the Wolverines to 1-3 in a pandemic-shortened season. Questions were swirling about if former Michigan quarterback Jim Harbaugh’s would remain as head coach at his alma mater. The Wolverines would finish a the season a disappointing 2-4.

On November 15, J.J. McCarthy sent out this tweet:

What does this have to do with health care in Canada?

I have previously written about my own failures and setbacks. From dropping out of University in 1994 (and 1995, just to be sure), to going unmatched through CaRMs in 2003.

Match Day 2024 is March 19th. I could have simply reposted my Substack from last year and moved on.

But Michigan’s 2023/24 run to the National Championship was calling me.

Anyone who knows Michigan football understands how it works. They run the ball down your throat. They tell you what they are going to do and then challenge you to stop them. Four yards and a cloud of dust. Big Ten Football.

Former Michigan QB Tom Brady played with a chip on his shoulder his entire career. After winning a national championship at Michigan in 1997, Brady was drafted 199th in the 2000 NFL draft. He was not expected to be the GOAT, experts weren’t even sure he would make the team. Yet 10 Super Bowls later (and 7 rings), he is the undisputed greatest Quarterback of all-time (talk to me about Patrick Mahomes in 20 years).

After Michigan’s loss to TCU in the College Playoff last year, McCarthy stood on the field and watched TCU celebrate.

As detailed by Sports Illustrated: “There’s perhaps no greater insight into an athlete’s psyche than seeing how they act following a crushing loss. Michigan quarterback J.J. McCarthy gave fans a small glimpse into his mindset after the Wolverines’ devastating 51–45 defeat in Saturday’s Fiesta Bowl.

Playing in the College Football Playoff for the second straight year, Michigan (13-1) was unable to overcome a handful of missed opportunities and came up just short in the national semifinal against the Horned Frogs.”

I see a lot of Brady in McCarthy. Quiet confidence. A leader of men. Resolve in defeat.

Today, J.J. is QB1 for the 2024 College Football National Champion 15-0 Michigan Wolverines.

J.J. enters the 2024 NFL draft this spring. A lot of people (usually Buckeyes) question his ability. They call him a “game manager.” They doubt his arm strength.

Going unmatched in 2003 gave me some serious doubts about my abilities. My skills.

Was it a mistake to go into medicine? Could I be happy in another field? Did I leave the stove on?

Today, I am the only physician in North America with Fellowship in the College of Family Physicians before Canada, Royal College of Physicians and Surgeons of Canada and the American Association of Hospice Palliative Medicine.

The NFL draft is much like the CaRMs match. It distills years of hard work and sacrifice into one binary answer: matched/unmatched.

To my fellow UnMatchable: Take 3 deep breaths…and have faith.

“Destiny is calling. Open up your eager eyes.”

#GoBluE

PS I rushed the field at Michigan Stadium for the first time this year when the Wolverines beat THE Ohio State Buckeyes (again). Destiny calls.

I then watched the Championship game with my friend Mark, who recruited me to Windsor. Destiny calls.

Dr. Alex Duong: The Challenges Facing an Early-Mid Career Family Physician

Dr. Alex Duong, a family physician from the Vanier district of Ottawa (which amazingly enough is one of the more underserviced areas of Ontario).

Recently, Maria DiDanieli, the clinical lead for system navigation at the Burlington Family Health Team, published an opinion piece in Healthy Debate that was critical of the decision of Drs. Alam/Mathew and yours truly to recommend that family practice residents bide their time instead of starting up a comprehensive care practice in Ontario. Dr. Duong replies and has kindly allowed me to reproduce his reply here.

I am a full-time community family physician, and I read this article with great disappointment.

I am at the face of our health care system. When patients cannot get a timely breast biopsy or a knee replacement, they come to ask me. I address their frustrations, alleviate their pain, and manage expectations.

I am the backstop when issues are missed during transitions in care and issues that require follow up.

I am the navigator that helps patients, and their families orient themselves to housing resources, mental health and financial resources.

I am the advocate for my patient’s health when they deal with their employer or insurance companies.

I do all these things and more, alongside everything from newborn care to palliative medicine.

I, like the great majority of family physicians, take pride in our work, and in what we contribute to our patients and the community at large. But Banks do not grant loans for a new clinic based on my contributions to Ontario’s healthcare system. My rent payments do not decrease because of the positive impact I make on my patients’ lives. The salaries of our exceptional staff are not funded by the sound of clanging pots and pans.

Today, to outfit a new clinic with the minimum number of physicians for a FHO requires high 6 figures to 1 million dollars, loaned at 6.95% interest. We guarantee our own lease – we are on the hook for ensuring it gets paid for the entire term. We are responsible for hiring and ensuring our staff are paid a living wage. We invest our own time in making sure the clinic runs. For many community family physicians like me, there is no assistance for any of this from any level of government. No money for staff, no incentives for starting up, no support for logistics. We are in a precarious, failing business model with ever growing administrative burdens patching the system equal to a part-time job. We have been trying to expound on this, and frankly have been completely unsuccessful in this.

You realize that “… there does not seem to be much political will to improve this situation at this time.” Yet, you ask family physicians to work harder expecting a different result from the government.

You state that “With these current barriers and shifts, any new practice can feel fragile or vulnerable to imminent obsolescence.” Yet, you expect new graduates to take on a massive financial risk: long term lease, EMR contracts, and double their already tremendous debt in start-up costs.

You lament that “Instead of acting as beacons of wisdom, encouragement and level-headed advice, we see a growing shift toward inciting everyone to walk out!”. Do you apply this standard to the teachers in Quebec who recently concluded a strike? Are they less dedicated to their students? Do you apply this standard to all groups who organize to make their voices heard?

The authors, Drs. Alam, Gandhi and Mathew made it clear that there are many options available to new family doctors. They warn of the current state of specifically locking into comprehensive family medicine, to ensure that new grads do not put themselves in a position where they will be burnt out early in their career. To me, leadership requires honest conversations, not empty promises, or exploiting the ideals of new family doctors. I find it unethical to sell a romantic vision of what it is like to start and maintain a Family Medicine practice in the current environment. It is a recipe for moral injury when those ideals run flat into the economic realities, as I have experienced.

And frankly, to say to those of us, like myself, still practicing longitudinal family medicine we should be working harder, or we are just doing family practice wrong is demoralizing. It is grossly offensive to my early-mid career family medicine colleagues who have burnt out through great moral struggle and guilt. Disillusioned family physicians who leave longitudinal family practice will not return. The greater harm to the public and to patients is not the Star article that speaks truth to the issue, but the issue itself: that family physicians, whose concerns are being gaslit, continue to leave longitudinal practices.

Dr. Soni Reflects on the Delays in Emergency Rooms

Dr. Deepa Soni, and Emergency Room physician for over twenty years, reflects on the case of a young woman with appendicitis, and the delays in getting her care.

NB: Recently, Julia Malott spoke out on X (formerly known as Twitter) about how terrified she was about Canada’s health care crisis. She wrote how her daughter had not eaten in 18 hours as she continued to wait for surgery for appendicitis. She expressed concern about the lack of the beds and wondered if her daughter would get surgery before the appendix ruptured.

My friend Dr. Soni, who has worked in an Emergency Department for over 20 years, had, as usual, a very thoughtful and well spoken X thread of her own. (Dr. Soni was NOT involved in the care of this young woman). I thank her for allowing me to reproduce her thoughts here.

The only way these stories (about long delays in Emergency rooms) will stop being the norm, is when patients start sharing their experience like this mother did. Only voters can make federal and provincial governments change because votes are the only currency that matter. Doctors and nurses have been raising alarm bells for years without success.

Canada has one of the lowest number of hospital beds of all the OECD countries, around 2.3/1000 people. In comparison countries like Japan, Korea and Germany are around 13/1000.

Graph showing how Canada fourth from the bottom (!) in hospital beds per capita.

Why does this matter? Having low hospital bed numbers means that words like “flu surge“, and “winter surge” — which have been used for decades to explain away long wait times and hallway medicine, are actually not “surges.” Rather, they are the expected backlog in a system that lacks adequate beds and resources.

The population of Canada is increasing and aging. We are about to enter a silver tsunami where a large cohort of our population will be over the age of 65 and many over the age of 85. This will place unprecedented pressures on our health care system.

What happens when the hospital bed capacity is outstripped by the numbers of patients needing care? It means that the elderly patient who needs admission to a hospital bed to recover from a heart attack has no bed to go to and spends days “admitted” in the emergency department. Bureaucrats call these “unconventional spaces.” What they really are, are stretchers.

Photo of admitted patients lying in stretchers in a hallway as no beds available (found on X)

When the vast majority of the emergency department beds are being used to take care of hospital patients, that means that patients that are waiting in the emergency department waiting room, will wait for hours for care, much like this story is describing.

Media needs to scratch beyond the surface and hold government to account. Real solutions are going to require thinking beyond the four-year election cycle. What will our system look like in 20 years? How do you plan for that?

It’s going to require recognizing the backbone of our healthcare system is primary care. Family doctors are overwhelmed by administrative burden, trying to run their offices and taking care of large practises in the community without adequate resources.

Build community infrastructure with resources like palliative care so that people can remain in their homes comfortably in their last days; and sufficient homecare services so that patients can receive antibiotics and other intravenous treatments at home to ease the pressure on hospitals. These services are vastly underfunded and do not have enough staff to properly provide care for everyone that needs it in the community.

It’s going to require building more nursing homes, retirement homes, seniors services and dementia care programs, as our elderly population will be the largest it’s ever been in this country.

Incentivize and properly pay hospital nurses so that we can recruit and retain them to be able to run departments and programs properly. Currently, agency nurses make at least two times as much as a hospital nurse, and this has created instability in the workforce. Governments need to show that they value nurses and the important work that they do.

Creative solutions like interprovincial licensing of doctors and nurses and a National Pharmacare program will help. While the idea of recruiting from other countries sounds like an easy quick fix, it will not solve anything if those newly obtained doctors and nurses find themselves overworked and burning out soon after arriving to Canada. The system problems are going to impact them just as they have impacted those who are already working in the system. This type of strain is what contributes to moral distress and burn out.

The backlog in the emergency department is a reflection of multiple failing areas that create an overall system that is strained beyond capacity. With each passing year, Canada’s healthcare system has become more and more stretched, trying to provide more care to more people, with fewer resources. Throwing Band-Aids at it is like trying to mop up the floor under an overflowing sink instead of trying to figure out how to turn off the tap.

Stories like this one are happening every day in Ontario and all of Canada. Most patients and families are too busy dealing with the acute health problem to take the time to write to their MP/MPP or to go to the media. But when people take the time to bring these stories to light, a critical tipping point will eventually occur where they can no longer be ignored by government. Because votes matter.

No one who went into healthcare wants to work in a system that makes patients feel like this story illuminated. But we need more voices bringing their stories out in the open. It will improve the system for the people working in it, and for the people receiving care within it. And that is better for everyone.

What Would I Do if I Got Sick? I Would go to Turkiye.

NB. I am a consultant for Medicte, a medical tourism firm that connects people with the Acibadem Health Group in Turkiye. I appreciate my two loyal fans may read this to be an “advertorial” – but it does represent how I feel.

Yours truly at an Acibadem Hospital in Turkiye with their team and representatives from Medicte

Recently, Leger released the findings of a survey that polled Canadians on their thoughts about the health care system. 70% of Canadians worried about not being able to get high quality health care. Surprisingly, only 37% thought the health care system was poor – did 63% not need medical care recently? But the number that should demoralize all of us is that only 17% feel the system will improve.

Like everyone else of a certain age, I’m coming to the realization that the one fight I won’t win, is the battle against time. More of my friends and colleagues are developing health issues. While I’m blessed to be in good health, like 83% of Canadians, I realize that the current health care system (which doctors call horrific and inhumane ), will not provide the access and care we should expect as standard in this country. I can only see things getting worse in the near future.

It does not help that I live in the health system every day. I’ve watched patients I really care about suffer in ways that I would not have imagined possible. Young people with cancer not getting treatment for three months. People with joint pain waiting a year for surgery. Patients developing complication after complication while on wait lists to access necessary treatments.

Most heartbreakingly, I see the toll that the burnout of working in such a hellishly damnable health care system is taking on doctors, nurses and other allied health care professionals on a daily basis.

That’s why I recently made the decision that if I, or someone in my family needed health care, I would seek care outside of Canada. I am not alone in this. The data is hard to get at, but going back as far as 2014, between 52,000 to 217,000 Canadians were seeking health care outside of Canada annually.

There are a variety of reasons to seek care outside of Canada, and specifically Türkiye:

Getting immediate care. I could get hip surgery next week, not next year. Cancer patients get all the tests they need done within a week, not three months like I’ve seen.
Getting treatments that are not available in Canada. Canada offers a host of great medical treatments, but many are not covered by government plans. Lap Band surgery is one. New, emerging radiation therapies for pancreatic cancer is another. There are more. All of these are available in Türkiye.
Getting better allied health care support. Canada has GREAT nurses and other allied health care workers. But the system does not let them care for patients the best. Last time I was on call at my hospital, I overheard the nurses talking about how they each had 7 patients to look after for the shift. The safe number for an acute care hospital ward is 5 patients per nurse. We have excellent nurses but if you are constantly working at 40% over capacity, things are not going to go well. At the Acibadem hospitals in Türkiye, they have 4 nurses for 15 patients (3.75 patients per nurse).
More cost effective care. I’m fortunate I can afford to pay out of pocket for care if needed. Worst comes to worst I’ll put off retirement for a couple of years to pay for things if necessary. But even I would have trouble with $200,000 (U.S.!) that B. C. resident Allison Ducluzeau spent on her cancer care. Costs in Türkiye for most procedures I looked at are generally less than half of what it costs in the U.S.
First World Standards for Health Care Treatments. All of the Acibadem hospitals are JCI Accredited (the global leader in health care accreditation agencies). This puts them on par (and in some cases better) than top European hospitals.
Türkiye is a well sought after Medical Tourism destination. Medical Travel Market recently highlighted 12 reasons why Türkiye was so well sought after including cost, world class facilities and cutting edge treatments. 1.2 million people went to Türkiye for medical tourism in 2022, mostly from Europe.

As part of my consulting work, I went on a fact finding tour to Türkiye and visited the Acibadem hospitals. To say my jaw dropped would be an understatement.

The team and I reviewing the process for orthopaedic care with their top spine surgeon.

The hospitals (there are 21 in the Acibadem group) look like hotels. Each room is private. The wards are immaculate. All of the staff were incredibly attentive (and yes, spoke English).

I asked to see the MRI, and the staff wanted to know which one (!). Their approximately 170 bed hospital had THREE MRIs, specialized for different conditions. This is on top of the CT scans, gamma knives (cancer treatment), PET scans etc etc. All of the equipment was brand new. I especially liked the MRI that projected a movie onto the equipment, to help children stay calm during the procedure.

This MRI projects a movie onto the surface to help children (and some adults) stay calm during a claustrophobic procedure

I also ran into a couple of top ranked Turkish footballers (soccer players) while there. The Turks are as crazy about football as we are about hockey. Their top athletes go to the Acibadem group.

But what’s more impressive than the top ranked doctors, nurses and equipment is their philosophy of how to provide health care. If you were to sadly, get cancer, you would see all the specialists you need to see (surgeon, medical oncologist, radiation oncologists etc) on the same day. Any tests you need would be organized sequentially and rapidly over the next couple of days (if not the same day). You would have a full treatment plan within a few days.

Contrast this with Canada where you have to have an appointment with one doctor, then wait x number of weeks to see another then x to see another like my patients currently do. All while the cancer continues to grow.

Also, for the record, I did wind up getting care myself at Acibadem. Bad teeth run in my family, and so I went for a dental check up. The dentist examined me, put in two fillings, got the oral surgeon to come by and took out two teeth that were beyond hope, all during the same visit. This would have taken multiple visits in Canada. You could say I put my money where my mouth is. And yes, the care was excellent.

I appreciate this sounds like an advertorial. But the reality is that more and more Canadians are getting frustrated with the long waits for health care and seeking care outside of Canada. It may have started off with people seeking lower cost cosmetic surgery, but now things like orthopaedic surgery, cancer treatments, organ transplants, dental implants and even cutting edge infertility treatments can be had for those willing to travel.

There is never a guarantee of a successful result with medical treatments anywhere (including Canada). If considering leaving the country for care, people should do their due diligence. Make sure you deal with a reputable firm and first rate hospital.

I’ve made my decision, and I know where I’ll go.

If you or anyone else would like to explore options for out of country health care, contact Medicte for a free consultation.

DFCM at Temerty Faculty of Medicine’s Stunt is DANGEROUS for Physicians AND Patients

I’ve been involved in medical politics for some time and in health care for much longer. I’ve seen a lot of foolish things. And yet, I confess, I’m still dumbfounded when some really smart people come up with a really stupid ideas. I guess I’m just a slow learner.

The most recent of these ideas comes from the Department of Family and Community Medicine (DFCM) at Temerty Faculty of Medicine. (Temerty is the name for the University of Toronto Medical School – and no, I have no idea when or why they changed their name to Temerty). In an attempt to address the crisis in Family Medicine, Drs. Pinto/Kiran and Martin would like the governments to declare a state of emergency in access to primary care.

Do I understand wanting to draw more attention to the crisis in Family Medicine? Of course I do. Family Doctors are planning to leave the field in droves. Compensation for family medicine has failed to keep up with inflation much less given them a raise. The admin burden makes one feel like Sisyphus (In Greek mythology Sisyphus was dammed by the gods to roll a boulder to the top of a hill only to have it roll suddenly back down to the bottom when it got close to the top and thus be forced to roll it up again. A more apt description of the family medicine paperwork burden I have never seen).

Heck across the country our whole health care system is in crisis, not just family medicine. Patients are not getting timely specialist care (some even choosing euthanasia as a result) as well as family practice care, resulting in worsening health care outcomes for all Canadians. We should be screaming about this.

But I honestly don’t think Drs. Pinto/Kiran/Martin (who combined have more letters after their name than the entire alphabet) could possibly have thought this recommendation through. Frankly, I’m genuinely left wondering if they even know what the government declaring “a state of emergency” means. The only way to enact this, is to invoke the Canada Emergency Act.

This Act clearly lays out what governments can do to solve a crisis in any particular area. And it’s not pretty. It includes:

giving the government the “ability to make orders or regulations that are believed, on reasonable grounds, to be necessary…”
Directing specified persons to render essential services…
Regulating the use of specified property, including goods…
The imposition of fines or imprisonment for contravening on any of the measures declared..

In short, having the government declare a state of emergency gives them a whole lotta power to do a whole lotta things. I guarantee you not all of those things will be smart.

No one in their right minds is going to argue with the issues identified in the letter three doctors wrote about:

The crisis in family medicine is real. There has been a lack of investment in primary care. This will get worse. This will cost the health system more money in the future if we fail to fix the problem. And yes, thank goodness somebody other than a cranky cynical old country doctor wants a significant overhaul and feels that “modest changes are not enough”.

But – to tell the government to enact a state of emergency, giving the same bureaucrats who have completely screwed up the health care system for the past thirty years almost unfettered power is not the solution. Let’s look at some of the goals of these three doctors:

If there is a state of emergency – do you know how these pointed headed bureaucrats will take “decisive action” to “ensure every person in their jurisdiction has equitable access”? You think they will licence more physicians? You think they will allow Ontario Health Teams (OHTs) to have strong physician leadership (which is the ONLY thing that has been proven to work in accountable care type organizations like these OHTs)?

I got news for you. The pointy headed bureaucrats will simply mandate zones, unilaterally determine how many patients a doctor must roster, and will make decisions in the interests of “urgency” given the new powers they just got from a state of emergency to show they are doing something.

Say for example the recent situation when Royal Victoria Hospital had to close down their obstetrics service. Hell that Gandhi fellow delivered babies 20 years ago, he probably hasn’t forgotten what to do – send him there to cover so it doesn’t close, he’s only 45 minutes away. Or a hospital about close their ER again – force a local doc who hasn’t worked in ER for 15 years to do so. 7,000 patients without a doctor in a certain town? Have each family doctor take a couple hundred more – even though those docs are already working night and day. (Trust me – these ideas will not sound outlandish to bureaucrats.)

Drs. Pinto/Kiran/Martin know that to make inroads into solving the primary care crisis you need to do three things:

increase the payment to family physicians to reflect the work they do. Decades of sub inflationary wage increases (cuts by another name) have made it untenable to run a family physicians office. Pay family docs more and don’t be afraid to say so.
The OHTs actually have potential for improving health care, but they need strong family physician leadership – not any other health care professional (and certainly not bureaucrats) – family physicians need to lead this. (The OMA has plenty of evidence on this and has shared with the government and will share with you).
- Interchangeable IT technology that allows easy access to patient data and thus minimizes the admin burden.

The only reason I can think of for doing this is some sort of political stunt to embarrass the politicians. Heck I agree politicians should be embarrassed for how badly they’ve messed things up. But to do it in a way that gives them more power (not less) instead of demanding a true collaboration with family physicians doesn’t strike me as a very smart move at all.

OMA, CMA and CCFP Should put MEMBERS, not the Corporation, First

My thanks to Dr. Paul Hacker, pictured here, for his contributions to this blog. Dr. Hacker is a former Vice-Chair of OMA Council and a former member of the SGFP Executive. He’s a strong advocate for physicians interests, exceptionally well versed in governance and bylaws, and good friend.

As we approach election season for the Ontario Medical Association (OMA), many members have regularly brought up one issue to me. Is it true that the the Board Directors for the OMA are all asked to sign “an oath of loyalty to OMA central and not the members?”. The question is usually asked with incredulity and a tone suggesting a disappointing response.

The OMA is a corporation, as is the Canadian Medical Association (CMA) and the College of Family Practitioners of Canada (CFPC). There are many, many good reasons for these organizations to be incorporated, including preferential tax rates, some indemnification for members from assuming the debts of the corporation in case of financial difficulty and a requirement that bylaws and Boards adhere to certain standards.

If you think your membership fees are high now – just wait till you see what they would be if these organizations did not incorporate.

Good corporate governance demands that Board Directors of any corporation put the fiduciary interests of the corporation first. So yes, when I became an OMA Board Director, I did have to sign an agreement saying I would act in the best interests of the corporation. “Oath of loyalty” is a bit hyperbolic, but Directors are legally bound by their fiduciary duties.

In order to help educate Board members on their role, governance training is provided to them when they assume their role at the OMA. I assume this is also the case for the CMA and CFPC. The governance training is usually provided by some hot shot consultant (we got some guru from Rotman Management). Given the consultant’s list of degrees/publications after their name, there was an understandable (but still irksome) tendency for the staff at the OMA to value their opinions on Board matters over some Directors.

But this whole thing is frankly a crock when we are dealing with a membership representing organization (I told our consultant that). Fiduciary responsibility as Director of a for profit corporation whose goal is to increase share value is fine. But it’s quite another when the raison d’être of a corporation is to be a non-profit whose purpose is to advance the interests and needs of the members.

Let’s look at some examples.

I previously wrote about the atrocious 2016 tPSA between the OMA and the Ontario. What I didn’t mention is that that tPSA was actually really good for the OMA as a corporation.

No seriously. The agreement, if passed would have ended a period of internecine warfare between the dismal Kathleen Wynne Ontario government and the OMA, saving a bunch of money. More importantly, that agreement also created some bilateral tables where the OMA could be a joint partner and “co-manage” aspects of the health care system with the government.

There was to be a table on recommendations on physician supply and distribution. One to “co-manage” expenditures of the Physicians Services Budget. A commitment to work together on health reform and much more. In short, that agreement would have given the corporation of the OMA more power and a say in the health care system. All the OMA had to do was ruthlessly stab its members in the back.

Yet look what happened in the aftermath. The then Board was thoroughly repudiated in the ensuring vote. The first non-confidence motion in a OMA Board Executive occurred. Multiple special meetings were called. The resignation of the executive led to a protracted period where the OMA had no leadership or spokesperson. This is good for the corporation?

Want more? Let’s look at the Canadian Medical Association (CMA). In 2018 the CMA surprisingly announced that it was selling MD Management, which many of its members had relied on for their retirement planning. It’s hard not to see why they did it. The CMA got upwards of $2 billion dollars for the deal. The corporation of the CMA clearly benefited significantly and, unless it is financially managed by the same crew that ran Enron (remember them?) – will never go bankrupt and will live in perpetuity.

All it had to do is, you guessed it, stab its members in the back in a move that was widely viewed with a sense of betrayal. The outcome? In 2018 when Dr. Gigi Osler took over as president of the CMA, it boasted 85,000+ members. When Dr. Lafontaine took over in 2022, that number dropped to 68,000. I asked a friend of mine who is quite high up the chain at the CMA what that number is now and she told me she tried to find out, but apparently “they don’t give that number out any more.” Hmm.

NB: I realize correlation does not equal causation, but I find it interesting that the CMA stopped saying how many members it had after a grumpy miserable old coot pointed out the drop in numbers last year. The Medical Post often reprints my blogs – perhaps one of their intrepid reporters could ask the CMA how many members they have today.

Once again, the question needs to be asked, how does a drop in members truly benefit the CMA? How can they honestly say they “champion the medical profession” when they have fewer and fewer doctors as members?

We are seeing the same thing unfold with the College of Family Physicians of Canada (CFPC). They recently announced the truly idiotic suggestion that it was fair to raise their membership fees by 7 %, and the even dumber suggestion that the residency should increase to 3 years from two. They are now embroiled in a serious controversy over this and their annual meeting promises to be a mess. (Both of these moves would benefit the corporate CFPC of course – but not the members or the public).

The pattern is abundantly clear. When Directors of membership corporations don’t put members first (not the corporation), the corporation will suffer. I hope whoever runs for Director of the OMA has the intestinal fortitude to politely confront whatever “governance consultant” is brought on, and tell them just that.

We Should Return to the Health Care Model Tommy Douglas Envisoned

In 2004, the CBC surveyed Canadians to see who would take the title of “The Greatest Canadian.” The winner was former Saskatchewan Premier Tommy Douglas. Douglas is widely, and correctly viewed as the founder of socialized health care in Canada.

His selection speaks not only to the dramatic impact he has had on this country, but just how much Canadians value health care. I will dispense with calling it “free health care” because that just isn’t true. Our tax dollars pay for it. But those dollars are supposed to provide care for all those who need it.

Tommy Douglas, the Greatest Canadian, and the founder Medicare.

As our health care system continues to collapse all around us, it’s worthwhile, I think, to look back at the type of health care that Douglas envisioned. The truth of the matter is, that it is quite a bit different than what we have today. And I think, is not at all what Douglas would want.

According to “The Canadian Encyclopedia“, Douglas’ views on health care were shaped by a number of events in his early life.

As a six year old, Douglas fell and cut his knee. Unfortunately, he developed osteomyelitis ( a bone infection) and the consequences hampered him for his entire life. He had numerous operations and at one point doctors in Winnipeg considered amputating his leg. Fortunately, a well know orthopaedic surgeon (Dr. R. J. Smith) offered to operate for free, so long as Douglas allowed medical students to watch. This saved Douglas’ leg, and helped convince him that health care should be readily accessible to everyone.

Later, as a young man, he moved to Weyburn Saskatchewan, and was dismayed by the complete lack of medical care. He buried a 14 year old girl who died of a ruptured appendix because she couldn’t get medical care. He also vividly told of burying two young family men in their 30s, who simply couldn’t afford to get medical care.

These experiences helped to shape his belief that we could do better as a country. I would suggest that all Canadian should share the belief that one should not have to choose between going bankrupt (or dying) and getting basic medical care.

As premier of Saskatchewan, he implemented the Saskatchewan Hospital Services Plan covering the needs of patients admitted to hospital. In 1961, he implemented the Saskatchewan Medical Care Insurance Act, that provided medical insurance for all residents of Saskatchewan. This of course eventually led to other provinces and the Federal Government adopting similar programs.

The wording is important, and I think speaks to what Douglas was trying to achieve, and frankly, where I believe we need to go back to. The plan was “Insurance”. With all the benefits, AND RESPONSIBILITIES that go along with insurance.

Here’s the thing. In Canada, ever since the Canada Health Act, we have really deviated far from what Douglas really envisioned. He never ever wanted a system where you could go to any health care provider and get assessed without any responsibility on your part. Indeed, he spoke to that quite eloquently in the Saskatchewan Legislature on October 13, 1961:

“I want to say that I think there is a value in having every family and every individual make some individual contribution. I think it has psychological value. I think it keeps the public aware of the cost and gives the people a sense of personal responsibility. I would say to the members of this House that even if we could finance the plan without a per capita tax, I personally would strongly advise against it. I would like to see the per capita tax so low that it is merely a nominal tax, but I think there is a psychological value in people paying something for their cards. It is something which they have bought; it entitles them to certain services. We should have the constant realization that if those services are abused and costs get out of hand, then of course the cost of the medical care is bound to go up.”

Douglas intuitively grasped that if people perceive something as “free” they will start to lose their sense of using it responsibly. That’s why the initial Medical Insurance Act was just that. A form of insurance funded by the taxpayer, and like all forms of insurance, there was a deductible and reasonable limitations.

People were able to now access health care, for a small fee that allowed them to recognize that they too had to take some responsibility for how they used the system. They also had to realize that not everything was covered. Basic health care yes. Options like wanting, say, a private room instead of a ward bed in hospital – well that would be an extra.

There are many problems with the Canada Health Act. But the most fundamental is that it is based on the premise that you can endlessly get something (in this case health care) for nothing. Gutless politicians (from all parties) continue to promote this mantra in never ending attempts to woo votes as opposed to, you know, actually telling the people the truth. Namely, that people should take some responsibility for how they use the health care system.

By continuing to perpetuate the the lack of accountability, our cowardly politicians have created a culture of entitlement instead of a culture of empowerment. Many (not all) people believe that they should be able to get all manner of testing because it’s “free”. I’ve been blessed to have a very pragmatic practice in general, but even I have had to tell people that I will not be ordering the serum rhubarb levels their naturopath wanted because it would be “free” if I ordered it instead of them, or the full body MRI that some “wellness consultant” asked for.

It’s time to bring some patient accountability back to health care. And the first step in that would be to go back to the model that Tommy Douglas had proposed all along.

Dear OMA Board Member, About That Mandate for Negotiations

Dear OMA Board Member,

I read, with interest Ontario Medical Association (OMA) Board Chair Dr. Cathy Faulds update last Friday. There’s the usual information in there about the goings on at the OMA (which sadly not enough members pay attention to, though they should). Critically for most members however, was this comment by Dr. Faulds:

“The board will hold a special meeting at the end of September to finalize the negotiations mandate for use by the Negotiations Task Force (NTF)..”

This is a big step in the negotiations process and to truly understand that, members need to understand what a “mandate” is. Allow me to briefly expand on what Dr. Faulds wrote. The short version is that a mandate is the minimum offer the NTF can accept from the government. If the government offers an increase that is equal to or exceeds the mandate, then the NTF will automatically accept that offer on behalf of the Board.

The corollary to that, which some Board members did not understand when I was on the Board, is that if the mandate is met, and the NTF accepts – then it will automatically mean that you as a Board have to accept the offer as well. As per Board rules, you will then have to endorse the government offer to the membership. You can’t very well tell the NTF “you must achieve XYZ”, and if they do achieve XYZ, turn around and say it’s not enough.

Therefore, it is incumbent on you as a Board, to make sure the mandate is sufficient for the membership as a whole, given the times we live in, and the environment around us.

To that end, without spilling specific secrets, I will state that there was quite a lot of discussion about what an acceptable mandate was during my time on the Board. There were some Board Members who wanted to be “reasonable” and some who wanted to take a hard line and keep the mandate high.

I would, respectfully, point out that for the most part, mandates are never met. Usually the NTF comes back to the Board with “we tried – but this is the best we could get” and presents that to the Board. To be clear, I’m referring to all labour negotiations in general, not just physician ones. Negotiations Legal Counsel told us this last time, just ask them. Whatever you (or any Board) sets as the initial mandate, there is a strong chance the NTF will come back to you later and ask you to lower that mandate.

You will need to keep that in mind when setting your mandate.

To that end, I would encourage you to recognize that the time really has never been better to set the bar extremely high for the NTF mandate. It’s not just that physicians are considering leaving the profession. It’s not just that health care is collapsing all around us. It’s not just the ongoing problems with not just recruiting, but retaining physicians. You already know about all of those issues in excruciating detail.

No, the reality is that we now also have some significant competition for physicians within Canada from other provinces. And I mean strongly significant.

Not sure how many of you have seen this summary form the recently approved Physicians Services Agreement (PSA) in Nova Scotia. On the surface there would appear to be a fairly minimal 10% raise over four years. A deep dive however shows significant add ons like improved parental benefits, funding for overhead, funding to hire allied health care professionals, funding for admin work, enhanced FTE and income stabilization for specialists and so on. That plus a retirement fund!

Similarly, in Manitoba, their recent agreement was widely hailed as a landmark and a game changer. I spoke to a friend of mine from Manitoba who confirmed that it too contains things like a retention bonus ($21,000 and higher for those in rural communities), funding for admin time, funding for new models of care, additional funding for those patients who are older and an equity lens applied to fees. In short, the increase is widely viewed to be in the double digits percentage wise per year.

Look, I know the NTF knows all the stuff I’m pointing out (but others who read my open letter may not). I also would acknowledge that Dr. Mizdrak is a fine chair for the NTF and is (in a very good way and said with total admiration on my part) a real pitbull on behalf of the profession. I also have full confidence that the NTF did it’s due diligence in reviewing the many asks by the leaders of all the specialties.

But at the end of the day, it is up to you, dear Board Member to set the minimum acceptable deal (mandate) and it is up to you dear Board Member to ensure that Ontario remains a competitive place to attract physicians.

To that end, you must ensure that if there is a negotiated agreement, it must at least equal the increase in Manitoba or Nova Scotia (whichever is higher). Anything less would, quite frankly, be rightly viewed as the Board selling the profession out. (If we wind up going to arbitration, that’s a different story – but at least we will have gone there because the Board refused to take a sub optimal deal).

All of which is a long way of saying that since it is quite likely that an initial mandate may not be met, it is incumbent on the Board to set a mandate for the NTF that is HIGHER than what was achieved in Manitoba/Nova Scotia. This will allow for the usual process of the NTF having to come back and say what parts can be achieved and what can’t, and allow some wiggle room.

If you set the bar lower, well, frankly, I have to wonder how you can justify saying that you are advocating for the Doctors of Ontario.

Yours truly,

An Old Country Doctor.