Category: Family Medicine

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.

How To Stop the CFPC’s Plan to Increase Residency to Three Years

PLEASE NOTE: This blog has been updated with new information, and to remove an unfortunate aspersion that was cast on the administrators of the PFI Facebook group.

Recently, the College of Family Physicians of Canada (CFPC) announced plans to increase the Family Practice residency to three years. This is, in my opinion, the stupidest decision they have made in my 31 years of practice. They should fix the current residency program instead. They also announced plans to increase the fees that family doctors pay by 7%, at a time when most family doctors are struggling to stay afloat. This would be the second stupidest decision the CFPC has made in my 31 years of practice.

There is, however, some hope. Some members have gotten some private members motions onto the agenda for the CFPC Annual General meeting. If enough ordinary members vote for those motions, it will pressure the CFPC Board into doing the right thing and stopping the implementation of these changes. In typical Ivory Tower fashion, the CFPC has made the voting process exceptionally convoluted. It’s so labyrinthine that it made we wonder if it was done on purpose to discourage members voting. Ivory Tower types don’t usually like listening to the masses.

However, a step by step detailed set of instructions on how to vote down these proposals were posted by Dr. Liz Zubek on her Facebook page. Dr. Zubek stresses that this is an accumulation of information gathered by many doctors and she herself has copied and pasted much of it to form the final set of directions.

Dr. Liz Zubek, family physician from Maple Ridge BC. Dr. Zubek posted instructions on how to vote at the CFPC Annual General meeting.

Dr. Zubek forwarded to me the detailed instructions that the CFPC doesn’t want you to see on my blog. Here’s how to vote ONLINE and IN ADVANCE of the Annual General Meeting. You do not have to attend in person and can do it from your comfy (?) office chair.

From Dr. Zubek’s Facebook page:

There is an ability to vote down the 3rd year of residency with private member motions buried in the agenda for the upcoming CFPC AGM, plus the ability to vote for transparency asking the CFPC to post something as simple as board and committee minutes, so we can actually see how they come to their decisions that make no sense to us …..and we can also vote on their wish to increase our yearly fees. But it isn’t easy to vote!

These are instructions for how to vote by proxy in advance in the CFPC annual member meeting taken from another post: How To Vote, CFPC 2023

1. Find the two emails from Oct 11th called “1 of 2” and “2 of 2” (search “Participate CFPC” if you’ve already deleted them). Click where it says “Register here”:

2. That will take you to a new page. The “control number” to enter here is in the “2 of 2” email from October 11th . You may have to type it in because copy and paste hasn’t worked for a number of people.

3. Once you hit “Login”, it will take you to a new screen. Here, select “Yes, I wish to appoint a proxy”. This means you are registering your vote ahead of the meeting and don’t have to attend the meeting. (If you do end up attending, you are allowed to change your vote):

4. After you press “continue”, it will thank you and then send you two more emails that will take 20-30 minutes to arrive. NEW INFORMATION: Despite doing this 12 hours ago (as of this writing), I have yet to get a second email. Some physicians have told me it is now taking up to 24 hours to get an email. Many are complaining that they are having difficulty logging in in the first place.

5. Open the new “1 of 2” email and click on the weird looking “lumimeet” link and use the password that’s in the new “2 of 2” email to log in. Again, you may have to type it in because copy and paste hasn’t worked for a number of people.

6. You’re almost there! On this page, you can now click to read all the motions if you like. When you’re ready, you click the “Voting” tab at the top and you can…vote!

7. In the interest of democracy, I will not tell you how to vote. However I will tell you that I voted “no” to the fee of increase and “yes” to the next four motions for greater transparency, information as to how the 3rd yr decision was made, a financial impact report of the 3rd year, and to put a hold on 3rd year implementation. Hope this is useful! Now go and vote!! It’s so important.”

You MUST vote by MONDAY OCTOBER 30, 2023 at 5:00 pm!

My two cents:

This grumpy old country doctor intends to vote exactly like Dr. Zubek did. No to the fee increase. Yes to the next four motions. It’s unclear at this time whether these motions are binding on the CFPC Board. But at the very least, us ordinary members have to say our piece.

My initial blog, which I do believe was factual, commented on the fact that this post had been deleted from the Facebook group PFI by the administrators. The author had also been removed from the group. The way I wrote about it unfortunately cast aspersions on the administrators of PFI. That was inappropriate on my part and for that I am truly sorry. My goal was to comment on the fact I felt (and do still feel) it was inappropriate to remove a member without warning, but the initial way it was written suggested something more. That was wrong of me. My apologies again.

But one thing at time. Vote to stop the 3 year residency and fee increases first. Then let’s find out how the situation became so unseemly so quickly.

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.

#Docxit on the Rise, Means More Trouble for Our Health System

Acknowledgement: I want to thank my friend Dr. Graham Slaughter for coming up with the term “Docxit”. Graham is not only a brilliant internist, but is incredibly talented at wordplay and music. Plus, he has really thick, lustrous wavy hair!

A bunch of stuff has come to my attention recently in my social life and on my social media feeds. I’m saddened by all of these and even more saddened by what this means for the residents of Canada.

Item 1: a friend of mine in her early 40s confided she is going to give up her family practice. She loves her patients, but the admin burden and the poor remuneration make it no longer feasible to do this work.

Item 2: two more friends of mine, also in their 40s, are actively making plans to leave medicine altogether. One of them told me she knew four family physicians (all in their 40s) who left this year alone, and two others in their 30s who have moved out of country.

Item 3: I came across a social media post from a friend of mine from my days in OMA leadership announcing he was now a real estate agent. Amongst the people congratulating him on passing his real estate exams were other physicians also saying they were look at ways of getting out of medicine.

Item 4: The family health organization I’m part of in the Collingwood area has gone from 52 family physicians to 47 as some have retired without finding a replacement, despite trying.

Provincially of course, there are many more such stories. Three family doctors in the Ottawa area left their practices earlier this year. Twenty per cent of family doctors in Toronto are planning on closing their practices in the next five years. The list goes on.

It’s not just Ontario. British Columbia is facing a “dire picture” when it comes to family physicians. Doctors Manitoba, through their excellent (now past) president Dr. Candace Bradshaw, pointed out the need for more doctors on more than one occasion. I could probably find articles from every province highlighting issues with recruiting and retaining physicians, but you get the point.

Doctors, it seems, are looking at leaving the profession (for either retirement or other jobs) in alarmingly high numbers. This phenomenon, dubbed Docxit by Dr. Slaughter, is happening at a time when our health system can arguably least afford it (if it ever really could).

This is particularly a concern as our younger physicians seem to be more likely to quit. A report by Statistics Canada suggested that up to 47% of physicians with less that 5 years experience are intending to leave or change jobs in the next three years. To be clear, they are not intending to retire, just do something other than what they’ve trained for.

From Statistics Canada

This phenomenon is not just present in Canada. The American Medical Association is concerned about “Medicine’s great resignation” as 1 in 5 physicians in the U.S. are also planning an exit in the next two years.

The situation in Europe would appear to be even more dire. The Politico article I linked to states that seven million people in France do not have a family doctor, with more family doctors retiring than setting up a practice. There is a shortage of two million health care workers in Europe. Brexit has badly worsened the shortage of doctors in the United Kingdom. Spain is running out of doctors. And so on.

Once again, those leaving appear to be over represented by younger physicians. It’s so bad that European Junior Doctors (an association of younger doctors in continental Europe) issued a press release warning the health care system there was going to collapse.

What’s going on then? Why are so many doctors leaving? I mean, despite the few (but loud) vociferous miscreants on social media, being a physician is still the most respected profession in the world (at 83% we’re tied with farmers and scientists). Studies show that Canadians trust their doctors to make the right choice for them and are afforded a measure of leeway that politicians and bureaucrats must surely be envious of. And you know that stereotype about first generation South Asian immigrants always wanting their kids to grow up to be doctors because of their status in society – it’s true (trust me, I and many of my friends lived it).

But the reality is that over the past ten years, practicing medicine has devolved to where it is no longer about caring for patients (which is what all good doctors want to do). In Canada, it’s been about fighting bureaucracy. With doctors now spending up to 19 hours a week doing paperwork (that’s a half a work week for most people) or fighting nameless, pointy headed, basement cellar cubicle dwelling bureaucrats to get them to actually pay for surgery that a patient needs, medicine is now more about who can do paperwork better than who can promote health care better.

In the United States, the rise of corporate entities eating up private medical practices has fuelled an explosion of a different kind of paper work, all with its own stresses. One study suggested that each physician spends almost $83,000 U.S. a year interacting with insurance companies.

Add to that the ludicrous number of options and waivers and liabilities and I sometimes think it’s easier to understand Einstein’s Theory of Relativity than it would be to understand U. S. Health Care. Dr. Glaucomflecken does an excellent job of explaining the frustration here:

I don’t know what the reasons for #Docxit are in Europe, but I imagine they are similar. The over bureaucratization of medicine is taking its toll everywhere. As was stated in the Politico article:

“At its core, it’s really that there is the perception that potentially medicine is no longer an attractive career choice, a choice for people to stay in for a whole career. And this will really endanger the sustainability of health care systems in future,” – Sarada Das, secretary-general for the Standing Committee of European Doctors (CPME)

There are so many crises in our health care system right now, it’s honestly hard to keep track. But two things are for certain. First, we won’t be able to fix health care without retaining doctors. Second, as more doctors opt for Docxit, we would appear to be doing a lousy job at retention.

Dear CFPC Board, Provide Business Training to Family Physician Residents

Dear Board of the College of Family Physicians of Canada (CFPC),

There’s a whole lot of talk about the crisis in family medicine. Even the College of Physicians and Surgeons of Ontario felt compelled to do a cover story on this issue. I’m just a (not very) humble ordinary member of the CFPC, so I don’t need point out the ramifications to the health system to such learned members as yourselves.

I fully respect that it will take a multi-lateral approach to fix this. However, the impression one gets is that the CFPC is focusing on extending the family medicine residency to three years, from the current two.  This expansion has even been presented as a possible solution to recruitment woes.

Nancy Fowler, executive director of the CFPC, states that the current program is “way too compressed” to deal with increasing complexity of health needs in Canada, changing technologies, and greater awareness of the health impacts of racism. In the same article, she also notes that residents have told her they would like more opportunities in different kinds of practices and settings (basically that they want the extra year).

I think these arguments are weak. The most learning I ever got was in my first year of practice. There is simply no substitute for being out on your own.  Join a supportive group like I did, and you will be fine.

I do respect that the current training program may not be adequate. I’ve taught many residents myself over the past 25+ years. The amount of useless “clinic day backs” and forums, research days and “behavioural science modules” that the residents are asked to do has increased to the point where I wonder when the residents actually, you know, see a patient in real life. No wonder they may feel unprepared for having their own practice. 

University of Toronto and McMaster – I’m looking at you.

But the solution to that is, you know, fix the residency program. Not extend it with a year of the doing exactly the same nonsense that made residents feel inadequate to practice comprehensive family medicine to begin with. All that would mean is that after three years the residents will still feel unprepared.

Also, have you considered that if you do increase the residency by a year, you will have one year where NO family medicine residents graduate into practice? Would you care to explain to everyone how that will help the current shortage of family docs?

Anyway, if you do increase the CFPC residency to three years, would you at least add some practical training for our younger colleagues to the residency? I believe they would benefit from two months of their third year being dedicated to learning about the business of running a practice. How to hire people. Employment standards. Performance appraisals for staff. Negotiating leases. Finding the best prices for supplies. And yes, how to maximize your billings.

All of those above tasks (and more) are absolutely essential to running a comprehensive family practice. Yet NONE of those are taught in medical school or residency. In fact, in many universities, the feeling one gets when one brings up the idea that we should teach something as simple as billing is that you have spoken of that which shall not be spoken of, lest the appearance be created that your desire to practice medicine might even in the smallest part be less than altruistic and rather more about a hedonistic desire to generate a fair income.

The horror, the horror!

And yes, McMaster and U of T, I’m looking at you (again).

These are practical business skills all of us absolutely need to run a practice and isn’t the point of residency to, you know, make the residents comfortable running an actual practice in real life? Additionally, the reality is that we now face the existential threat of corporatization in family medicine.

This is how it works.  A corporate clinic, let’s call them  The Haleness Infirmary goes to a young family doc.  They whisper siren like inducements like “Let us do the business of medicine for you”.  “We do all the admin work so you can practice the medicine.” “We believe in high quality patient centred health care you can trust” and other alluring catch phrases.  These clinics are almost always owned by some large corporation. Let’s say in this case, a pharmaceutical chain called Buyers Pharmaceutical Bazaar. All to entice the young, business naive family doctor so sign up with their chain.

The Haleness Infirmary could care less about the doctor they hire, or the patients they serve.  What they want is the gold mine of patient data.  It allows them to create a digital profile of the patient to target you with ads to sell products, because, the patient is nothing more than a commodity to them to be exploited. 

It’s absolutely true that there are privacy laws that prevent individuals from collecting your personal information. Funnily enough, those laws don’t apply to software or AI.  Software can figure out a lot about you based on your spending habits (it’s why if you look up say mattresses on a website once, you get ads for mattress stores on your social media feeds for a week).

If you go to Haleness Infirmary, the software would identify you as someone who needs cholesterol pills, and therefore you would see targeted ads for cholesterol lowering products (all sold at a special discount at Buyers Pharmaceutical Bazaar) so you can buy more products (and get extra points if you enrol in their Choicest points program which collects even more of your personal data).  Nice ecosystem.

Don’t believe this is their goal? When I was OMA President, one of the pressing issues for OMA Legal was the fact that doctors who left (or were asked to leave) these fancy corporate owned clinics– suddenly found they no longer had any access to their notes or patients’ charts (“owned by us and only for use by our employees – and you are no longer one”).

The holier than thou types that haughtily profess that they are better than us for not teaching basic business skills of course would be the first to be horrified that patient data was being used for marketing (gasp!) and making money (double gasp!).  The irony that their own belligerent refusal to teach basic business skills drives physicians to these corporate clinics is, of course completely lost on them.  It’s hard to see irony why your head is constantly tilted upwards befitting your lofty altruistic ideals.

Extend the CFPC residency to three years if you must. But for the love of Allah/God/Yahweh/insert deity of your choice, at least give our future colleagues an appropriate education that teaches all aspects of running a comprehensive family practice.  You will be doing them, and patients, a huge service, whether you realize it or not.

RePost: Marcus Welby Couldn’t Handle Today’s Medicine

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Admin Burden That’s Really Killing Family Practice

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

https://twitter.com/docter_audrey/status/1621738233875816448?ref_src=twsrc%5Etfw%7Ctwcamp%5Etweetembed%7Ctwterm%5E1621738233875816448%7Ctwgr%5E4e6147a2734a089709fba7d9ea702653111e2ee9%7Ctwcon%5Es1_&ref_url=https%3A%2F%2Fjustanoldcountrydoctor.com%2F

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Why does it matter?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Federal-Provincial Health Care Deal Fails Canadians

This blog has been updated to reflect that the fact that the offer from the federal government has been accepted by the provinces.

Lots of chatter about what is an agreed upon funding formula for Health Care between the provinces and the federal government. Some astronomical dollars are being thrown around and called investments in health care. But at the end of the day, will this deal mean better health care for Canadians? The sad answer, is likely no.

One of the advantages(?) of being old is that you’ve lived through lots of things, and can see the past repeating itself. Case in point, in 2004 then Prime Minister Paul Martin introduced a health care “accord” that was designed to “fix health care for a generation“. Essentially the federal government ponied up an eye watering amount of money then, and the provinces were to implement targeted programs that would:

  • Reduce wait times
  • reform Primary Care
  • Develop a National Home Care program
  • Provide a National Prescription Drug Program (by 2006!)

Now Primary Care reform did happen in Ontario, with the development of capitation based payments to family physicians. Think of it as a salary with performance bonuses and you get the gist. There was also the implementation of some Family Health Teams. I’m unaware if any of these were implemented in other Provinces. I do note with interest that British Columbia is only now getting around to reforming primary care with their own new payment model for family physicians.

But both of these programs in Ontario were summarily slashed by then Health Minister Eric Hoskins and his servile deputy Health Minister Dr. Bob Bell in 2015. Indeed their unilateral freezing of the capitation model significantly damaged primary care in Ontario, and the effects of their folly are still being badly felt today by the 2 million residents of Ontario without a family doctor.

OMA Board Vice Chair Audrey Karlinsky put it best on Twitter.

Wait times for surgical procedures however, continued to rise, and I have no idea whatever happened to the National Home Care program.

For those of you paying close attention, the same Eric Hoskins who stopped Primary Care reform in Ontario, went on chair a federal advisory council with the goal of creating a National Prescription Drug Program……….in 2018. Which hasn’t been implemented yet. I suppose being 17 years overdue is not bad by government standards.

By the way, this whole process is basically recycling a failed politician to recycle a failed government promise. And politicians seriously wonder why average Canadians like me are so cynical??

So now, 19 years later, Canadians are being told that the provinces have accepted a federal government proposal to put an eye watering $196 billion into health care, according to Prime Minister Trudeau. But wait they were committed to $150 billion anyway so it’s really only $46 billion more, but wait, when you take out the planned budgeted increases it’s only $21 billion more. Whatever.

In return, for however much money it really is, Trudeau promises there will be “tailored bilateral agreements to address“:

  • Family Health Services
  • Health workers and the backlog of health care
  • Mental health and substance abuse
  • Modernized health care system

Our politicians need to study Albert Einstein a bit more.

Here’s the sad truth about our health care system that no politician, of any political stripe seems to be willing to admit. The system is dying and in need of radical surgery. It needs a bold, transformative vision that will completely change the way we deliver health care and will leverage technology appropriately. Anything less is simply more of the same, and will not stave off the inevitable collapse of the system.

How then do we achieve this transformation that is essential to the well being of Canadians? I will go into some further thoughts about this in future blogs, but first I would implore our political leaders to stop listening to old voices who have been advising for decades (if their advice had been good we wouldn’t be in this mess). It’s time to seek out some newer voices who have bright ideas on how to restructure health care delivery in Canada.

It’s also time to wrest control of health care data management from the current group of bureaucrats in charge of it. We can’t transform health care in Canada without a robust health care IT infrastructure and the current group simply is not getting it done.

As mentioned, I will put some more though into how, in my opinion, health care can be transformed in the future. But for now, just know that whatever the numbers or promises being tossed around, the blunt reality is that it all amounts to trying to spend you way out of trouble.

When has that ever worked out well?