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

Dr. Silvy Mathew guest blogs for me today. She is hands down one of the smartest people I know. She writes about her experience in visiting the ER to help a family member. Dr. Mathew has been a strong advocate for health system reform and it is a loss for all Ontario residents that her warnings about the impending crisis in health care were not heeded by Health Ministers dating back to Eric Hoskins.

A few days ago I was in the Emergency Room (ER) with a family member. The ER was slammed. The paramedics were lovely and about four teams that I could see were stuck in waiting room, waiting for their patients to be triaged. We were on a stretcher by the front sliding doors. Almost outside.

We were there for urgent imaging, and possibly consultation. We tried to do this in the outpatient setting, but lack of access to both urgent images and consults for urgent care makes that impossible. So we go off to ER by EMS (needed for transport).

I’m fortunate. I am able to fill in gaps. I can advise triage what issue is, as they can’t do physical exam in the waiting room in front of what seems like hundreds of people. I can provide medical information on relevant questions. I can monitor the patient status for changes.

I did remind staff after several hours to check blood sugar as my relative is an insulin dependent diabetic, now off food/fluids. I did remind about necessary medications to be given. Of course, if I wasn’t there, they may have reviewed the chart closer but they were clearly slammed and trying to manage.

And we weren’t in distress. My family member was unable to advocate for themselves. We got imaging about six hours in, and I watched the imaging staff, working with 50% less nursing staff, literally just running in and out moving people. Doing their best.

We had excellent care from people busting their butts. But so many potential falls through the cracks and errors. Twelve hours later, we got home, luckily without any new issues from ER. And we had a plan. And we had a specialist who called first thing in the a.m. to ensure we have close follow-up.

The system in Ontario has relied for decades on individuals and work-arounds making things work (like above) when the system design is archaic. Successive Ontario governments have refused to participate in strategic multi-pronged co-design, instead of piecemeal band-aids.

I have worked for 15 yrs in Ontario health care. I’ve witnessed how far things have fallen and how none of our work arounds previously used are available now after the Covid 19 pandemic, for multiple reasons. I’ve participated with the Ontario Medical Association and sat on bilateral committees with the government to try to advocate for system change.

I’ve witnessed how siloed and unaware most people outside of primary care are. Family Medicine is the canary NOT the Emergency Department. The issues that have caused this system collapse have been occurring since 2012. Many of us, especially Dr. Nadia Alam, tried to be loud and warn.

Last year, in 2021, we gave up. It was obvious to us it was too late. We heard for years from our mid-career colleagues about how they couldn’t do this anymore. How they wouldn’t work in a system that didn’t allow them ANY joy or success while taking more and more from them personally.

Covid-19 just pushed the dial a bit faster. The family doctors who were hanging on from retiring have chosen to live now (not leave, but LIVE). The mid-career family docs are struggling as mentioned above and also choosing to leave family medicine if possible, because nothing is working in it. Obviously, new graduates are terrified.

And so here we are, and the CCFP answer to this is to ADD a third year to residency. Because somehow they think adding more school, asking people to take on more debt, delay starting their lives longer, while having less non-academic preceptor support will somehow help?

What it will do is: add even more fuel to the family medicine crisis and shortage. It’s not gonna teach you how to run a business (last I checked real life experience mattered more). It’s not going to teach how to manage complexity in real life. It WILL drive more people out of family medicine residency.

What we REALLY need is a re design of the health system. You want people to do this job? LET them. You want family doctors to work at the top of their scope? ENABLE them. Support access to resources OUTSIDE of hospital and provide help to coordinate.

Stop advocating for more debt and school CCFP, and advocate for real life mentorship, group practices and shared care. You want Emergency Rooms to not house people? Fund home care and long term care. Fund resource teams to support those in seniors neighborhoods already. Use a community approach.

While we are at it, stop spending all the money on pharmacology. Fund allied health, encourage exercise programs and healthy meals because that’s WAY more useful than the hundreds of thousands of dollars of Botox we spend on contractures AFTER they occur. Keeping people mobile keeps them out of hospital and long term care.

The Canadian media can stop asking if health care has collapsed, anyone working in it knows it has. It will show in a year or two, when the numbers of late-diagnosed cancers, life expectancy and other markers of care get affected. But in real-time we are seeing it now.

If we don’t have some real leadership here and some true innovation, we are in for some truly sad times in the next decade. End.

Does Ontario’s Digital Health Strategy Meet Our Needs?

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

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

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

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

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

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

Some recent examples from my practice:

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

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

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

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

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

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

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

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

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

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

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

What Role Should Nurse Practitioners Play in Health Care?

A recent look at some of the news stories around health care do not paint a pretty picture for Family Medicine. In Ottawa, a truly wonderful 41 year old Family Physician (whom I had the pleasure of meeting when I was OMA President) is closing her family practice due to burn out. The BC government is on the defensive over the shortage of Family Physicians. Medical School graduates are avoiding Family Medicine. The list goes depressingly on, but the point is clear.

Family Medicine is in crisis.

Jumping into this environment is former Ontario Deputy Health Minister Bob Bell and his colleagues. To fix Family Practice, they recommend expanded use of Nurse Practitioners (NPs), allowing them to work independently to replace much of what family doctors do. They claim that NPs can independently provide care for rosters of 800 patients, and collaborate with Family Doctors only for more complex patients. The authors reference a British Medical Journal (BMJ) study that suggests this will be “cost-saving.”

Bell doubles down on his beliefs that NPs can replace family doctors on Twitter by cherry picking data, in this case a Cochrane review:

One wonders if Bell and his colleagues bothered to read the reviews. If they had, they would have seen that the BMJ study on “cost-effectiveness” admitted:

“…it was not possible to draw conclusions about the cost-effectiveness of the complementary provider specialized ambulatory care role of nurse practitioners because of the generally low quality of evidence.

And that the “authoritative” (Bell’s words not mine) Cochrane review also stated:

We are uncertain of the effects of nurseā€led care on the costs of care because the certainty of this evidence was assessed as very low.

For those of you not versed in medical literature those phrases are the author’s way of saying they did studies where the results couldn’t be relied upon to be reproducible. Using these to promote a belief that allowing NPs to work independently to replace family docs is…….puzzling.

Bell’s belief that Family Docs are easily replaceable is nothing new. He planned on actually ending his career as a general practitioner. Apparently he thought he could easily slide back into it after having done it for a couple of years early in his career, then gone on be an orthopaedic surgeon for another few decades before getting involved in health administration and the MOH:

I don’t personally attribute any malice to his statement (though others on that thread did), I’m not sure that that Bell realized just how much he insulted every single GP in Canada with his seeming belief that he could simply suddenly switch gears after 4 decades of not being in primary care, and go back to being a GP without at least a residency. Hate to tell you this Dr. Bell, but Family Medicine has changed a LOT since you last practiced it. We have more than just beef or pork insulin for diabetes for example.

More to the point however, is there data out there that actually looks at the kind of system that Bell and his colleagues would propose? One where NPs scope of practice is drastically increased allowing them to work independently, and they replace the bulk of work that Family Doctors do? Turns out, there is.

In South Mississippi, the Hattiesburg Medical Clinic, an Accountable Care Organization that is very similar in structure to the proposed Ontario Health Teams (OHTs), did exactly what is Bell and his colleagues are proposing. Fifteen years ago, based on ongoing shortages in Family Physicians, NPs and Physician Assistants (collectively referred to as Advanced Practice Providers or APPs) were hired and allowed to work separately and independently with physician colleagues.

Did this work? In a word: Nope.

A comprehensive analysis of their findings (minimum of 11 years of data over a large patient population) was published in the Journal of the Mississippi State Medical Association. You can read the details for yourself but here are some highlights:

  • the cost for looking after patients who did not have end stage renal disease (i.e. were on dialysis) or were not in nursing homes was $43 a month higher per patient for those who were looked after by APPs than family docs
  • when the data was adjusted for complex patients, the cost of having an APP look after them, rather than a family doc was $119 per month higher (!)
  • these costs were attributed to ordering more tests/more referrals to specialists and MORE emergency department use (yes MORE)
  • Physicians performed better on 9 out of 10 quality metrics in the review

In short, doing what Bell and his colleagues are suggesting led to poorer overall health care outcomes at an increased cost.

Now to be completely clear, I personally have worked with NPs in a number of ways. I strongly believe they are an essential part of the health care team and provide a valuable service. In my practice, they have assisted me in providing care to my patients. When I had a couple of “cardiac kids” in my practice, I dealt exclusively with the NPs on the cardiology team at the Hospital for Sick Children (never once spoke to a Cardiologist or Cardiovascular Surgeon). When the Royal Victoria Hospital in Barrie had NPs on their oncology service, I discussed issues around cases with them exclusively. The NPs were at all times incredibly helpful to me and my patients. NPs definitely have a role to play.

I would also point out that the Hattiesburg Medical Clinic feels the same way. They strongly valued their NPs, and still have them on staff. But they have modified the way they provide care to ensure that all patients now have a Family Doctor but the visits to the clinic now alternate between the Doctor and the APP. On days when only an APP is in house, telemedicine back up by physicians is provided.

We need to build a better Family Practice system. In order to do so, NPs can and should play an essential role. That role however, is not taking on independent rosters of patients. It is working as valued members of a team that looks after a patient population, where each patient has a Family Doctor.