High Dose? Standard Dose? Doesn’t Matter! Just Get A Flu Shot!

Recently, many physicians offices have been inundated with requests for the so called “high dose” flu shot. I know I’ve had many patients ask in my own office, and this is the result of all the publicity around these shots. Pharmacies were specifically advertising that they had the high dose shots available. Heck some pharmacies even offered customers points for getting your shots. Until of course, they ran out. (Memo to pharmacies – unlike Teslas, generally not a good idea to advertise something you can’t deliver on time).

Of course once they ran out came the inevitable concerns expressed about why people couldn’t get a “high dose” shot themselves. I have also heard some isolated reports in my community about people waiting to get their flu shot until the high dose were back in supply.

But here’s the thing. There is no evidence to suggest that the high dose flu shot is actually better than the current standard dose shot. Seriously.

In 2014, a study was done looking at the high dose versus regular flu shots, particularly in older patients. The study clearly showed that there was a higher immune response in older patients with the high dose shot. But from a clinical perspective, it really only made a minor (although what statisticians will call a statistically significant) difference. 1.9% of people who got the standard flu shot went on to get the flu, and 1.4% of people who got the high dose flu shot went on to get the flu, for an effective difference of 0.5%. All this hype for 0.5%??

But more importantly, that study looked at what are called trivalent flu vaccines. In essence, both the standard and the high dose vaccines in the study were good against three strains of the flu.

However, in Ontario, our standard dose flu shot is a quadrivalent. It’s good against four strains of the flu. The high dose continues to be a trivalent. So the option for people in Ontario is to get a flu shot that has a regular dose against four strains, or a high dose shot that is good against three strains only.

Importantly, there has not been a head to head study between the high dose trivalent and the standard dose quadrivalent used in Ontario. Which means no one really knows which vaccine is better.

Heck even the Public Health Ontario Fact Sheet on flu vaccines states there is “insufficient evidence” to recommend one over the other. There is some supposition about the extra B strain that is covered in the quadrivalent vaccine not being as common in those over 65, and perhaps having a lower disease burden, but it’s not really clear cut.

So what should you do?

As I mentioned in my last blog, you should wait until November to get your flu shot. It now being November – GET IT! If you are over 65 and are unable to get the high dose, don’t sweat it, just get the standard one. Because frankly the protection you get from that is still really really good (I mean why all this fuss over a measly 0.5%??). But don’t put off getting your shot now just to wait and see if more high dose vaccines are coming.

It’s time to protect yourself and your loved ones. Both flu shots are good. Get whichever one you can, and let’s help each other stay safe.

Me getting my flu shot at the hands of my trusty nurse…..

Get Your Flu Shot…..in NOVEMBER

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

Above image from St. Patricks Home of Ottawa.

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

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

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

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

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

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

Graph is from the excellent Ottawa Public Health website

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

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

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

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

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

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

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

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

Physician Autonomy Essential for Good Patient Care

Several years ago, one of my colleagues was having a disagreement with an external health care agency. She’s a very bright young family physician, and is extremely passionate about one part of comprehensive family medicine care. She really felt the external agency was failing in providing a reasonable level of service for one group of marginalized patients. In particular, she felt the agency’s process for accepting referrals was deeply flawed.

After months of advocacy by her, the agency finally reviewed their intake process. They then pronounced that everything was ok, because 90% of the referrals were processed accordingly.

In response, my tenacious colleague sent an email to all the family docs in the area, asking them for feedback on the referral process. She the proceeded to blast said agency for the 90% processing rate. “If a server at McDonald’s got the order wrong 10% of the time, would he still have a job?” was the line in her email that really got everyone’s attention. As a result, my colleagues sent feedback, the external agency’s response was proven inadequate, and changes were made. In her own way, my colleague was following the wisdom of Ruth Bader Ginsburg:

It also shows, in one neat example why physician autonomy is so important to patient care. Because without that autonomy, and independence, we can’t speak out. We can’t advocate for our patients even if it makes bureaucrats uncomfortable. We can’t expose those situations where patient care has been compromised.

This is, of course, exactly what those who want to take autonomy away from us want. For the most part this includes two types of people. First are health care bureaucrats, who feel that because they control the purse strings, everything should be done their way, and no pesky front line physicians should dare question their judgement or expose their flaws. The second group consists of a small number of physicians, who, while well intentioned, feel that physicians autonomy impedes whatever fancy new health program they want to implement.

Suppose you are an employee in the IT department of a corporation. You make a statement like say, “If our legal department worked at McDonald’s they would get fired because they get orders wrong 10% of the time.” What happens then? Human Resources gets involved, you get called out for making derogatory comments, the CEO might even get involved, you get disciplined and basically told to shut up. Even (especially?) if you are right in the first place.

This is exactly what those who oppose physician autonomy want.

The anti-autonomy crowd feels that physicians resist change. Therefore, the thinking goes, physicians will use their autonomy and independence to impede whatever new program/model/team is being promoted. Hence, autonomy must be curtailed so physicians can do what they are told, and accept whatever the powers that be tell them is good for them.

However, this couldn’t be further from the truth. The vast majority of physicians are open to new ways of doing things. If they truly believe a new process will help their patients, and help their lives, they will adapt. This is why we use new medications, new treatment protocols and yes, newer models of health care delivery than we used in the past. Medicine would not have changed so much in the past 25 years, if it wasn’t for the willingness of physicians to explore newer and different methods of delivering health care.

But as my friend’s example shows (and there are many like hers), what is essential to the provision of good patient care, is for physicians to retain their ability to speak out. My friend saw an area where a health care agency was failing a group of patients. Because she didn’t have to fear retribution in the form of being hauled up in front of Human Resources, she was able to effectively advocate for patients (who in this case happened to be too frail to advocate for themselves). Eventually, due to her persistence, the agency recognized their errors and fixed their flawed process.

In much the same way as we explore transforming the health system again (in Ontario these are to be done with the Ontario Health Teams or OHTs), it is fundamentally important to ensure that physician autonomy is protected in these models. This will allow physicians to speak up if the implementation plans are not going the way they should, or if programs promoted by the leaders are not really going to help patients. While painful for those in charge to hear criticisms, it results in better outcomes in the long run because the new programs will be better, stronger and more effective.

Let’s hope that as the new OHTs are developed (full disclosure, I support the concept) the message of the essential nature of physician autonomy is not lost. Physician autonomy has allowed us to be the best possible advocates for patient care in the past. If we can no longer, as Ginsburg urged, fight for the things we care about, it will be the patients who suffer.

Integrated Health Care: If Not Now, When?

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

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

Reaction from many physician leaders was generally positive:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The “Feminization” of Medicine has Widened the Gender Pay Gap

Dr. Michelle Cohen (pictured left), a family physician from Brighton, Ontario guest blogs today. Opinions are hers (although in this case I share them). This article was initially published in the Medical Post and is reproduced here, with her permission, so that it is “ungated” and available for all.

What happens when certain types of medical work become synonymous with women’s work?

Women have moved into medicine in huge numbers over the past four decades. This is usually viewed as a good news story of social progress in a profession that had either banned or severely restricted female entry well into the 1960’s.

In this excellent paper by Dr. Elaine Pelley and Dr. Molly Carnes, the authors begin with a discussion on gender segregation in the broader workforce (in the US). It generally decreased thought the 20th century  with the entry of women into the workplace, but then stalled in the mid-90’s and ticked back upwards slightly.

When a large number of women enter a previously male dominated occupation, it will quickly move towards female predominance. This phenomenon is known as “tipping” and it has not been shown to happen in reverse (i.e., men don’t tend to take over fields seen as “women’s work”). When an occupation hits the gender tipping point (which varies roughly from 13-45% female), entry of men rapidly declines. This is the pattern demonstrated by teachers, secretaries, bank tellers, etc.

In academia and professions requiring high educational attainment, a tipping phenomenon occurs at 24% female. In other words, once a field is one quarter female, men start to lose interest in it. It loses prestige and the ineffable qualities granted by gender exclusivity.

What’s the evidence that a field loses prestige with female entry? At around the 38% female mark, interest from both men and women starts to decline. Research also shows an inverse relationship between how challenging a field seems and how many female PhDs are in it.

This is where we need to talk about the #GenderPayGap. Because not only do female dominated occupations earn less than male dominated occupations, historical data shows that each 10% increase in female share results in a 0.5-5% decline in earnings.

The gender pay gap is at its simplest about paying women less for equal work. But the gendering of occupations plays a major (and often overlooked) role. Research on high skill occupations shows men essentially take a pay cut when they enter female dominated professions.

This brings us to medicine. A profession with dramatic gender segregation among its specialties and little-to-no introspection on the impact of this phenomenon. In Canada, female representation among medical specialties varies from roughly 10% to 75%.

Historically, once women were allowed into medical school, they were immediately shunted into the specialties that seemed appropriate. Ones that involved babies or so-called “soft skills” like counseling. They were strongly discouraged from entering macho fields like surgery.

I say “historically” but of course, these ideas remain as strong as ever (that’s what happens when your industry lacks introspection on its own subculture). Ask any woman in medicine and she will tell you lots of stories like this one.

Naturally, we lack data on the gender segregation of specialties over time. If you can’t see a phenomenon, you can’t study it, right? Fortunately, Dr. Pelley and Dr. Carnes dig into historical data, showing that U.S. gender segregation in medical specialties has remained static since the 80’s—that’s my entire lifetime. American medicine has remained frozen in the same sexist ideas about women and men’s “natural” skills since the Reagan years.

Is Canadian medicine any better? We haven’t analyzed historical data (yet), but I think you know what I would say.

This paper does what few have: It looks at how feminization of a specialty impacts its relative earnings over time. This is such an important analysis and I can’t believe we don’t have more like these.

For example, pediatrics went from 22% to 63% female since 1975, but orthopedics has remained nearly the same. Subsequently, pediatrics went from earning 93% of the average MD salary to 71%. Meanwhile orthopedics went from 160% to 180% of average. Or consider obstetrics and urology. Obstetrics has lost relative income since the 70’s while going from 8% to 57% female. Meanwhile, urology has maintained its relative earnings (125% of average MD salary) while remaining at >90% male.

While I haven’t looked at historical data in Canadian medicine, I have done a lot of work analyzing the gender breakdown in specialties and their relative incomes. Those results will be published next month, but let me summarize it quickly now:

Gender segregation in Canadian medical specialties is a major factor in the gender pay gap. There are many other relevant factors at play, but the shunting of women into “female-friendly” specialties while discouraging entry into male dominated specialties plays a huge role.

We need more discussion on how women entering a field devalues it. We also need to broaden this analysis to include all of health care, which is full of women doing vitally important and shamefully underpaid work.

We Need to Learn to Live With COVID-19

“All of this has happened before, and will happen again.” – Lt. Kara Thrace, aka Starbuck, from the Battlestar Galactica (2004) TV show.

An advantage of being old is that whatever is happening, you have likely seen it, or something like it before. Every so often, society undergoes an upheaval and people have to change behaviours. For those of us who were around in the 1980s, there are some stark parallels to what happened then, and what society must do now in 2020.

The early 1980s were a different time not only for how we lived as a society, but for how medicine was practiced. This was particularly true with how we handled body fluids. As surprising as it may be to some younger readers, there was no such thing as universal body fluid precautions back them. If you had a known blood born illness like hepatitis, then sure, extra precautions were taken. But not for every body. When I was in medical school, there were multiple stories of a particularly nasty vascular surgeon who would squirt blood on trainees during surgery if they got an answer wrong to his questions. Needle prick injuries were routinely ignored. There was not a robust sharps disposal system. In short, it was very different.

A huge shift in society, and medicine, came when reports of a novel virus (sound familiar?) became publicized. This virus was new, deadly, and little was know about it. At first, this strange new illness seemed to only affect gay men. This led to all sorts of additional discrimination against the gay community, and even more ostracization then they were already experiencing. Mainstream media outlets routinely referred to it as “The Gay Plague” which clearly didn’t help matters. This also led to whack job conspiracy theories about its origins, some of which persist to this day.

This strange new illness was, of course, eventually named “Acquired Immune Deficiency Syndrome” or AIDS and the virus that causes it was identified (Human Immunodeficiency Virus or HIV). It was recognized that body fluid transmission could spread it and that it was not limited by sexual orientation. We learned it was possible to carry the virus and not have symptoms and you could get it from anyone.

And so, the age of universal blood and body fluid precautions began, and policies around this were implemented in hospitals and other health facilities between 1985-1988.

But there was also a shift in how society responded. Until then, most public service announcements around Sexually Transmitted Disease (like this painfully dated one from 1969) focused simply on encouraging people to get treatment after the fact. And accepting that it was possible for you (yes, sweet innocent you) to get an STD.

AIDS changed all that. Suddenly, an STD could be deadly. Suddenly there was no cure or vaccine. Suddenly, just getting treatment wasn’t an option, and education around prevention was mandatory.

With education, the public took precautions. “No glove, no love” was a popular catchphrase used to promote latex condom use as these were proven to significantly reduce the risk of transmission of STDs (including HIV). Public service announcements shifted to openly talking about prevention.

In short, people and society adapted, and changed behaviours to deal with this new virus.

Today of course, we are faced with a novel new virus, that is clearly deadly and is widely publicized. Little was know about it at the start, and we continue to learn about it. The virus seems to have originated out of China, and this has led to all sorts of anti-Asian racism (including from the President of the United States). There are whack job conspiracy theories about it. As we learn more about the virus, we know asymptomatic spread is possible, and that, yet again, anyone can get it. There is no vaccine (and despite Dr. Fauci’s optimism I’m not holding my breath) and no effective cure.

In response, hospitals and other health facilities are implementing new polices around Personal Protective Equipment (PPE). Hospitals are taking extra precautions around elective surgery as the risk of mortality in patients who get COVID19 infections peri-operatively is ridiculously high. In my office I now see patients wearing a mask, eye protection, and surgical scrubs that I immediately remove after my day is done.

And now too, society will be asked to change in response to this most awful virus. The simplest thing to do of course, is to wear masks when you are in an indoor public place, or better yet whenever you leave the house. As mentioned in an earlier blog, one only has to look at Japan where there was poor social distancing, packed public transit and no closure of their famous karaoke bars, but people wore masks, and the number of infections was extremely low. Wearing them also is key to restarting the economy so we can get on with our lives.

Next, we need to accept contact tracing. Aggressive contact tracing in South Korea was largely responsible for their low rates of infection. I was glad to hear that Ontario will be introducing an app to do this. I can already hear the cries of invasion of privacy, but if we are to control this virus, we are going to have to figure out a way to contact trace safely, and protect personal privacy at the same time.

The big difference between the AIDS epidemic of the 1980s and COVID19 now is, of course, the economic costs. The economy was never shut down then, and the kind of wholesale level of job loss we are experiencing now in (hopefully) once in a life time.

But if we are to get the economy running (and we must for a whole bunch of reasons, including the fact a good job improves overall health care), then society will need to adapt again. We did it forty years ago, and I believe we can do it again.

I am however, not looking forward to 2060…….

Critical Decisions Looming for Health Care

The past three months have seen us undergo a stress like we’ve never seen before in our lives. People have lost their jobs, been socially isolated, and, importantly, non COVID healthcare has been delayed significantly. It’s estimated that 12,200 hospital procedures are delayed each week in Ontario alone. (Back of napkin math suggests 125,000 procedures have been delayed since the start of the pandemic).

In Ontario, these sacrifices have had the desired effect. The number of patients with serious complications from COVID has been trending down. Because we are not able to test everyone, I look at the number of patients who are in hospital due to COVID, and especially those who are on a ventilator, as an indication of how widespread the disease is. Because Canadians did what was necessary to protect others, our hospitals have not been as overwhelmed as many had feared.

However, we are now facing another critical situation in healthcare. The complications that are arising in the people who had their healthcare delayed are reaching alarming proportions. Even at the best of times, our healthcare system was overburdened and overwhelmed. To add to all of that this additional backlog, and the fact that many of those patients have deteriorated and are sicker, and, well, you understand the dilemma we are facing.

I don’t have a degree in biostatistics, like current Ontario Medical Association (OMA) President Dr. Samantha Hill. I can’t crunch all the numbers and give you a statistically valid analysis of what we are facing. I can only speak to what I’m seeing in my own practice.

  1. a patient with significant stomach pain who had scans delayed for a month, only to discover cancer
  2. a patient who I diagnosed with melanoma, who still hasn’t gotten the required wide excision, and lymph node biopsy 8 weeks later
  3. a patient who sent me an email clearly indicating the desire to commit suicide because of the mental health effects of this pandemic (I got a hold of them and appropriate measures have been taken)
  4. a patient with a cough since January who still hasn’t seen a specialist
  5. a sharp increase in patients requesting counselling or medications for the stress and depression directly caused by the effects of the pandemic
  6. at least 5 patients who were already waiting for joint replacement surgery now delayed even more

Keep in mind that I am just one comprehensive care family in doctor in a province that has almost 10,000, and you get a sense of the scope of how much these delays are going to affect people.

This is why there is a real dilemma for those who make decisions about when and how to open up health care (and everything else). If we loosen restrictions, start opening the economy, and allow scenes such as what happened at Trinity Bellwood’s park, the number of patients with COVID will increase. But if we don’t, other people will die, or at least suffer life altering illnesses, from non-COVID related diseases.

In cold, unfeeling numbers, the worry by people like my esteemed colleague Dr. Irfan Dhalla is that we will accept between 10-40 deaths per day from COVID in Ontario. But the reality is that about 275 people a day die in Ontario from a myriad of causes (cancer, heart disease, stroke, suicide etc). What if the price of lowering the 10-40 numbers to zero, is to increase the 275 to 325? To be clear, I don’t know if we are at that point, and even more frankly, I doubt Ontario’s archaic health data systems could even help us figure it out. I just know that has to be a critical concern going forward.

So what can be done? The OMA has released a document on emerging from the lockdown, referred to as “The Five Pillars” paper. This is an excellent paper and it is worth reading. I would, however, add the following thoughts.

First, it’s obvious now, that wearing face masks going forward is essential. A look at Japan shows they did everything wrong, except wear masks, and they have one of the lowest COVID rates around. (And yes, I and others told people not wear masks before and in hindsight that information was wrong). This is particularly important to mitigate the expected second wave of COVID in the fall.

Second, we need to move procedures out of the hospitals where possible. Many procedures like colonoscopies, cataract surgeries, diagnostic imaging, minor surgeries and so on, can be done outside of hospitals. Ontario has an Independent Health Facilities Act which licences these premises and ensures that they follow a high level of standards. They tend to operate more efficiently than hospitals and can see more patients than hospitals (whole bunch of reasons why). Previous Ontario Health Minister, “Unilateral” Eric Hoskins stopped licensing them, and it’s a decision that desperately needs to be reversed.

Third, we need to get our health data collection done properly. In Ontario, the plan was to develop Ontario Health Teams (OHTs) throughout the province that would allow the different agencies that cared for a patient (hospital, home care, physicians etc) to co-ordinate care. As Drs. Tepper and Kaplan point out, “fighting this pandemic requires collaboration from every part of the system and the patient voice. That is the promise of OHT.” To do this properly requires seamless electronic integration of a patient’s health record, and this should also serve as the basis for collecting COVID data. A system like this could also aid with contact tracing if done properly.

For the sake of the health care of all Ontarians, we need to open up health care and the economy, and we need to do that sooner rather than later. With a little bit of vision and forward thinking, it’s possible to do this in a safe manner. Let’s hope that’s what we see in the next few weeks.

Better Contact Tracing Essential: Requires Improved Public Health Systems

Recently, I came across the following graph of the waves of the Spanish Flu in 1918-1919. I don’t know the exact source of this graph. However, the information on the graph lines up exactly with what the Centre for Disease Control (CDC) describes as the three waves of the Spanish Flu.

To be clear, nobody at this time knows if the same pattern will be followed by COVID19. We know that the flu tends to have decreased transmission in humid weather, but we don’t know if COVID19 (caused by a different virus) will follow that pattern. Or even if that will make a difference during the first season of a pandemic. There’s a nice video explaining that here.

However, should this pattern be followed by the COVID19, suffice it to say that we are all in for a very long road ahead.

So what can be done to reduce the intensity of the second and third waves (if they come)? Physical distancing of course is number one on the list. While many physicians (myself included) suggested not wearing masks in public initially, we know know that doing so will keep YOU from spreading COVID19 if you are a carrier. So wear a mask. Finally, we need a robust tracking and isolating system (aka Contact Tracing) for people who test positive for COVID19, which frustratingly, we don’t have right now.

Widespread testing for COVID19 along with Contact Tracing is what the four most successful governments in the world have done to control the spread of COVID19. We need to learn from these governments. But for now it is something that we seem to be unable to do in Ontario, and there are multiple reasons why.

Piecemeal Structure of Public Health Units (PHUs)

The first is the piecemeal structure of PHUs in Ontario. Now to be clear, PHUs are manned by terrific doctors and front line staff. I had the pleasure of meeting many of them during my term as President of the Ontario Medical Association and they are all excellent, hard working people. But the infrastructure of PHUs, from the point of view of this family doctor, leaves a lot to be desired.

By my count, there are about 40 Public Health Units across the Province. To a large extent, they work somewhat independently from each other and use different referral forms. My office has patients from patients in both the Grey Bruce and the Simcoe Muskoka health units, and while the staff in both units is excellent, it’s frankly annoying to have two different sets of forms to refer patients (and have two different formats of reports come in).

Worse, not all of the Public Health Units are on an electronic records (seriously, some use paper), and there is not one consistent electronic record for PHU’s across the Province. This only complicates the collection of data and the ability to Contact Trace.

Curiously enough, addressing the disjointed nature of the public health units was something that the current provincial government tried to address early in it’s mandate. Part of the initial plans were to reduce the number of PHUs and standardize the processes. This was supposed to result in savings of 25% in the PHU budgets. (NB – personally I can’t see that much in savings, I’m thinking closer to 10% would have been achieved).

Of course given what happened with the COVID19 pandemic, and the “two second sound bite” nature of our media reporting, the story has become “Doug Ford cut spending – we have a pandemic – solution – spend more”. It’s a nice simple argument. “Hey we spent more money, problem solved.”

However, just spending more on public health (and to be clear again – I support wise investments in public health), isn’t enough. There’s no sense in spending more on a disjointed system. What’s needed is to get all the PHU’s across the Province to integrate into one standard electronic system of record keeping, so that they can more efficiently and effectively contact trace.

More Wide Spread Testing for COVID19

Next of course, we still need more wide spread testing, and ideally we need something called “point of care” testing. Once again, the four countries I referenced earlier led the way in testing as many people as possible. So this needs doing as well.

APP for Contact Tracing

Finally, we really should authorize a provincial app for Contact Tracing. Alberta already has one. Alberta has taken many precautions to ensure that patient privacy is protected (app does not use GPS, has a randomized non-identifiable ID, erases data every 21 days etc). We could just use that one, or a more Ontario centric one like this excellent one developed by physicians . It has some what more features and ease of use but uses GPS. Better yet, why not link and App to a patient’s own health care portal like MyChart, which already integrates COVID19 test results?

As the New York Times pointed out, Contact Tracing is hard. However, we need to get on with it. Without effective Contact Tracing, we can’t mitigate against the potential second and third waves of this pandemic. Without mitigation, the economic and health disaster will continue and untold millions more will continue to suffer.

Here’s hoping that instead of just throwing money at a problem, governments of all levels invest smartly at the right tools (standardized PHUs, contact tracing APPs etc.) to deal with the COVID19 Pandemic. The alternative is too frightening to consider.

The Cruelty of COVID-19

We’ve been living with restrictions caused by the COVID-19 pandemic for over two months now. I recently lost a patient due to COVID-19, and this loss caused me to reflect on the effects of the disease, and it’s impact on society. There really is only one word to describe it.

Cruel.

This disease is unrelentingly, unwaveringly and inexorably cruel.

This has nothing to do with the actual pathology (the conditions and processes) of the disease. That in itself, is in line with a bad viral illness. You (mostly likely) get a fever,cough muscle aches, etc. In people who are predisposed (elderly, those with immune compromise) COVID-19 is more likely to get into the lungs and cause inflammation. There is, of course a much higher rate of death for those who have multiple other medical conditions.

Doctors have seen viral illnesses throughout the years, and this pattern of the weakest among us been more adversely affected is one that we are all aware of. Indeed, my patient was elderly and had a number of medical problems. Truth be told, it would not have been unexpected for my patient to have died anyway from any of the other conditions they had. While tragic and sad, the fact that COVID-19 took them when infected, is no real surprise.

Instead, however, the cruelty of this disease is manifested in how my patient, and the grieving family spent the last days. My patient was in hospital, isolated, and alone. No family could visit. No comfort in their last days and no ability for the family to say goodbye, which I know will haunt them for a long time to come.

But it is not just the patients with COVID-19 who are dealt this cruel fate at the end of their lives. Another patient recently died in hospital due heart disease and was COVID-19 negative. Didn’t matter, the new restrictions in place to increase physical distancing and reduce spread (all of which make sense on a population level), meant that they too, died alone, with no contact from family, and the grief of not saying goodbye will haunt their loved ones as well.

This doesn’t apply just to hospitals either. The local hospice (my community is fortunate to have one of these) has new, stringent guidelines in place for their palliative patients. Only one visitor per patient at a time. A maximum of two people allowed to visit at all (what happens if you have more than two children who want to say goodbye). Common area not to be used, so no sharing your grief with other families (which is often therapeutic).

Yes, I know, communication via online tools and phone is encouraged. But we humans are social creatures. We need to see each other in person. We need to hold hands. We need to hug each other. We need physical contact. Yet we can’t have it. Of course, this is necessary and appropriate. But that doesn’t make them any less cruel.

The further medical victims of COVID-19 are of course, the patients whose care has been delayed while waiting for the acute stage of the pandemic to pass. My patient who has a growth on her ovary, and has not been able to get a repeat scan (and worries daily about what it could be). My patient with chronic hip pain who was already waiting for 12 months for their hip replacement surgery before it got cancelled since it was “elective”. Numerous patients with cancer who have had their treatments delayed. The 35 (minimum) whom the Health Minister herself said may have died due to the care that was delayed by this pandemic.

Then of course, there are economic victims. The 44% (!!) of Canadians who lost work due to the pandemic. They now struggle with finding ways to pay the bills and provide shelter and food for themselves and their families. The toll as they struggle is heartbreaking.

We are also seeing an increase in domestic abuse, more people with alcohol and drug problems relapsing, and warnings of Post Traumatic Stress Disorder in physicians and allied health care workers who treat patients with COVID-19.

All of the above are victims of the cruelty perpetuated by COVID-19.

But in all that, there is, to my mind, hope.

There has also been this year an explosion of gentleness, kindness and decency amongst Canadians. Whether it is a grass roots group like ConquerCovid19 (which has, to my mind saved an untold number of lives and reduced morbidity), or simple acts of gratitude like shining a light for doctors, these acts make a difference. Whether you provide PPEs, or grocery runs, or other support to health workers, you are making a difference. Whether you call your friend to check on them after they have lost their loved one, or check on isolated seniors, you will make a difference. Whether you sing songs like these students or these doctors, you will make a difference (seriously, click the links, those songs are great).

Or if you are the unknown (to me) person who left this on the front lawn of my office building…

… you made a difference.

“Gentleness is the antidote for cruelty.”Phaedrus

Indeed, while it seems that COVID19 is inexorably cruel, the gentleness and kindness that has been exhibited by so many people proves that we will get through it, and we will succeed. It will not be easy. And we will need more kindness and gentleness than we thought possible, but we can do it.

Human kindness has never weakened the stamina nor softened the fibre of a free people. A nation does not have to be cruel to be tough.” Franklin D. Roosevelt.

Canadians have shown COVID19 what we are made of this year. We have shown it that its cruelty is no match for our kindness. We have shown it that we will beat it and all it’s complications, though it will take time and continued effort.

So continue to be good to one another. And together, we will win.

Mornings

Note: The following blog was written by new OMA President Dr. Samantha Hill (pictured). It was originally published on protecthealthcare.ca. That website is dedicated to supporting health care infra structure so that you health care needs are taken care of.

The alarm goes off.  I wake my kids, get them dressed, brush their teeth. I hug them a little longer than usual.  Run my hands through their hair. They get wiggly, and I let them out onto our balcony.  It’s an enclosed space off the third floor, about the size of a bedroom.   It’s fresh air, a space to be loud (sorry neighbours!) and some vitamin D.

We go downstairs, they get breakfast, I get tea, and I try to help get them set up for the day.  My eldest, the 5-year old, has e-learning.  He’s bright as a whip with the attention span of a pregnant goldfish, a wild creature who lives to run and move and make his friends laugh. These days are hard. He tells me he’ll try harder today, but I know he is trying as hard as his developing brain can.  This just isn’t how 5-year-olds are supposed to be learning.  The two-year-old is blissfully oblivious to most of the changes.  I kiss them both one last time and go to the door.  

Will today be the day I can’t come home?  Should I have hugged them a little harder, a little longer? My sister sees the look in my eyes and sends me all the strength she can: We’ll see you soon.  I am eternally grateful to her for being here, for having moved from another province to help me.  I’m a single mom, and a cardiac surgeon.  In these harrowing days, family support is a blessing I do not take for granted.  There are not strong enough words to express my gratitude.

I cover up as much as I can.  I am carrying only my hospital ID, phone, a credit card, and a folded cloth bag.  Everything, including my clothes, will get sanitized and washed when I get home.  If I get home.  My hair is tied up and covered to keep a layer between me and others coughing on me.  I wear a mask.  It won’t protect me, but as a health care worker I am more likely to contract COVID-19, and the rate of asymptomatic carriers is high.  I didn’t spend my life learning how to help people heal to be the vector that kills people I never met. Don’t worry though, I use the same mask everyday, no PPE wasted here.

I get to the hospital.  It’s familiar but different now.  The walls and doors and people are the same, but the vibe, the soul, it’s instantly heavy.  We are greeted by a masked security guard who ask for ID.  We queue six feet apart to scan our ID.  “Have you had any symptoms of the flu, fever, cough, travel history….”.  A quick no, and a beep, and we sanitize our hands.  Next step: “will you be in a patient-facing area?” and we are handed three flimsy masks in a plastic bag.  I thank the volunteer handing them out.  There’s no need to comment on how insufficient this is to keep me safe, my children safe, my patients safe.  We all know.  But we hold these masks like talismans, warding off evil.  May they be enough.  At least for today.  It’s a pandemic after all, front line workers can only deal with one day, one patient at a time.  If we look too far ahead the incoming tsunami will drown us in our own fear.  So for today, we take our masks, sanitize our hands and keep going. 

I tie on my first mask and head down the hall.  People give each other a wide berth.  We may be smiling at each other, but you can’t tell.  Fear looms in the eyes peering over the blue fabric.  Get my scrubs.  Try not to touch anything but I have to touch the handle of the scrub dispenser.  There’s no sanitizer nearby; it’s been empty for days.  I assume it gets filled but its always empty anyhow.  I use the plastic bag my masks came in to open the dispenser door, grab my scrubs and head up.  I open doors and press elevator buttons with the same plastic bag.  Finally get to the call room, open one last door and go inside to change.  Plastic bag in the garbage.  Sanitize hands.  Clothes come off and go into cloth bag, trying to only let the outsides of fabric touch each other.  Scrubs go on, and it’s time to head to the OR.  Walk quickly.  Don’t touch anything.  Clean hands often.  Don’t scratch my nose.  Don’t adjust the hair cover.  Don’t touch the mask.  Don’t panic.  Nothing has gone wrong, yet, today.

The OR feels more normal.  Most of us are used to seeing each other in scrubs, masked and hair covered.  There’s a bravado here to which I am well accustomed.  Fear isn’t allowed in the operating room; fear begets mistakes.  But everything takes longer than it normally would.  The nurses have run out of goggles and the case is delayed.  Anesthesia is double masking, gowning, covering necks, in a new system that requires a buddy and signs up on the wall to remind everyone of the new sequence.  Everything pauses for 15 minutes to let the invisible droplets settle.  This is very hard for teams driven by efficiency; we grow uncomfortable staring at each other and making small talk.  Fear nibbles at the edges of our consciousness, reminding us why all of this is necessary.  The minutes tick by painfully.  But if it keeps my friends and colleagues safe it’s worth it, every single minute is worth it.  Reports of doctors and nurses dying in New York, Italy and Spain are not falling on deaf ears.  

Do we have enough personal protective equipment (PPE)?  The worry niggles at us all.  Should we be sterilizing masks, saving gowns?  Two weeks from now will we remember aghast how we threw disposables away?  There it is, the whisper hinting at the roar of the incoming tsunami, rolling inexorably in this direction.  Stop.  Look away.   Focus on this patient; hope and pray that the claims of sufficient PPE are backed with supplies those of us on the front lines don’t see.

Focus on the patient, do our job.  Be kind to each other.  Maybe a little kinder than usual.  Tempers are high.  Everyone is a little irritable.  It’s the fatigue, the worry.  We are all self aware.  We know this is only the beginning.  But we are all in this together, and together we can make it through.

For more articles like this please go to protecthealthcare.ca