Specialists in Ontario are Being Played…

Looking through my in box, I see:

  • A report from an interventional radiologist, who performed a percutaneous vertebroplasty (injecting a bone in the spine with a form of cement) on a patient of mine with severe back pain.  She now walks without a cane.
  • A report from an interventional cardiologist who performed a very difficult cardiac stenting procedure (insertion of tubes in the blood vessels to the heart) on a patient of mine with unstable heart pain – probably saving his life
  • A report from an ophthalmologist, who expertly fixed my patients cataracts. She can now see her grandchildren clearly for the first time in years.

I think of colleagues like these (and many others) when I read about how Dr. David Jacobs, a radiologist and former Ontario Medical Association (OMA) Board member, would like to start a separate organization to represent specialists.  Dr. Jacobs is well known in the profession for his actions during what’s become known as the tPSA fiasco of 2016.  The former leadership of the OMA negotiated a deal with the despicable Kathleen Wynne government, but there were many questions about the process.  Dr. Jacobs exposed the situation in the press, and helped to stop a deal that would have effectively destroyed health care in Ontario.  It’s well known that I worked with him to stop this bad deal.  However, I think he’s on the wrong path this time.

I can appreciate how hard it must be for some specialists to feel good about the OMA right now.  On October 21, OMA Council passed an advisory motion recommending that the top three specialties might get cut by up to 6 per cent more (1% per year until 2024) than they have been already.  Most Ontario physicians unilaterally had their gross incomes cut by 7 percent by the desultory Kathleen Wynne.  Some of the higher paid specialties were cut more due to what’s known as targeted cuts.  If the OMA Board agrees to the Council motion, some specialists would be even more angry at the Association.

But the reality is that if Dr. Jacobs is successful in his endeavor, specialists will get eaten alive by government.  Any government.

The best example of split associations is in Quebec.  Specialists and Family Doctors each have their own associations. One can certainly see the appeal of going that route when you read stories about the big “raise” that specialists in Quebec got in 2015.  The “raise” was so large that some doctors actually protested it as being too much (no really) and wanted to give some of it back.

But one has to look at the facts first.  The deal was meant to compensate doctors for the fact that there was NO increase from 2007 to 2015 (fat lot of good having two associations did then).  Now, before the bulk of the “raise” sets in, a new government is in place and plans on eradicating it.  Who do you think can fight against governments more? Two small groups or one large one with more resources than either one?

Additionally, I’m not convinced that most specialists are aware of what the OMA is asking for in arbitration.  The OMA is asking for a repeal of all the cuts (targeted and otherwise), and normative increases (raises).  By contrast the small specialist group seems to only want the cuts repealed.  They have not asked for raises.  Why would specialists want to join a group that is asking for LESS at arbitration than the OMA is?

Here’s where this really hurts the specialists.  If I was the government, I would look at the fact that I was in arbitration with the OMA.  Faced with the possibility of physicians being paid more than I was willing to pay, I would try to divide the OMA.  I would probably send some sort of official to talk to the disgruntled doctors to encourage them on.  See if I could cause dissension in the OMA while I was fighting them in arbitration. If I was able to split the OMA, I would happily start to advertise the high gross billings (while ignoring their overheads) of this group of specialists and then use that to cut their billings even more in the future.  It’s called playing the long game.

Some specialists are understandably upset right now.  But under the current Arbitration process with the OMA, they still have the potential to recoup more of their lost income than this new group suggests.  Council also approved exploring potential dispute resolution mechanisms for relativity in arbitration.  If this can be organized in time, they would have a fair, impartial avenue to address their concerns.  Specialists will not have access to Binding Arbitration if they form a small separate group.  What are the chances that any government would freely offer a valuable bargaining tool like Arbitration to a newly minted organization?

Many doctors are frustrated with the pace of change at the OMA.  As someone who’s been accused (not altogether incorrectly I might add) of being too impatient himself, I understand that.  The OMA has made significant strides in the past year. More is planned.  But to bail out in anger only hurts people in the long run.

I worry that joining this group out of frustration and anger is going to further harm the specialists that I rely on to treat my patients.  They’ve taken a huge beating (as have all of us) the past few years.  The beating has not only been financial, but psychological and emotional as the loathsome Wynne government heaped scorn on doctors at every opportunity.

But in their anger, they are allowing themselves to be played by the government, and I fear they will be much worse off in the long run as a result.

A Few Random Thoughts

Disclaimer:  As always, just a reminder that while I am President-Elect of the OMA, the opinions in the blog are mine, and not necessarily representative of either the OMA as a whole.  I just like to tell people what I’m thinking.

Changes at the Ministry of Health (MOH)

Interesting change at the MOH.  Nancy Naylor, who was the second in command, has left the Ministry.  She is going over to the Ministry of Education.  I had the opportunity to work (briefly) with Ms. Naylor when I was on the executive of the Section of General and Family Practice.  I found her to be a very knowledgeable person and easy to work with.  I certainly wish her well.

However, as my loyal fans (both of them) know, I don’t particularly believe in co-incidences (Bob Bell suddenly “retired” when the Liberals lost?  Yeah, right).  At the MOH Ms. Naylor was the person the LHINs reported to.  Leaving that role during a transitional period is very curious timing.  Given that Premier Ford has instituted a hiring freeze on bureaucrats, that means that the LHINs don’t currently report to any one other than new Deputy Minister Helen Angus.  Frankly, looking after the LHINs as well as doing everything else the Deputy is required to do is a lot to ask.  Unless (and this is pure speculation on my part) this foreshadows the long hoped for elimination of the bureaucratic quagmire that are known as LHINs.  Be interesting to see how this plays out over the next couple of months.

Changes at the Canadian Medical Association (CMA)

This week, the CMA is holding it’s annual general meeting.  Dr. Gigi Osler takes over as President.  I had the pleasure of meeting her (however briefly) at the OMA Annual General Meeting in April.  Dr. Osler is a remarkable woman with more accomplishments in her pinky finger than I have in my whole body.  That the CMA is going to be led by her this year is unquestionably a benefit for the organization (given all their troubles this past year) and for physicians across the country.  Dr. Osler is an incredibly passionate advocate for physicians health and well being, and we are all lucky to have her speak out on such an important topic.

I do wonder how she is going to handle the internal politics of the CMA.  Based on the interview given by outgoing President Dr. Laurent Marcoux, it really seems to me that the old guard at the CMA (which still populates much of the Board and management) really doesn’t understand just how much they’ve alienated their members.  You would think the uproar created by their flawed “Vision 2020” mandate, not to mention the sale of MD Management, would have made them at least reflect on their path.  Physicians need a national advocacy association that places their interests first.  I hope the CMA recognizes that Dr. Osler’s popularity is because she speaks to that need, and that the old guard doesn’t try to silence her.

More Thoughts on the Strike in Thunder Bay

The strike at the Port Arthur Clinic was finally settled last week, after a bitter, acrimonious period that included a fence being put up, and criminal activity being committed by somebody.

I still worry about what this means long term for the Port Arthur Clinic.  They are all human beings there, and I can’t imagine that it will be easy for them to get back to work. It certainly will take years for the trust to rebuild.  I suspect, sadly, that we haven’t heard the last out of issues coming from this clinic.  I hope that first and foremost, the patients get the care they deserve.

Ontario Medical Association (OMA) Becoming More Outspoken

It’s been a couple of turbulent years at the OMA.  However, it’s nice to see that the leaders of Association speaking out more and more on physicians issues.  It started last year when Dr. Shawn Whatley was President and he advocated strongly for physicians first.  Through his many blogs (which are required reading for anyone interested in medical politics) and his multiple TV and radio appearances, he really got the ball rolling.   His simple mantra that you can’t improve health care by disparaging physicians, while self evident, really struck a chord and needed to be said.

This year of course, we have the incredible Dr. Nadia Alam.  Another ridiculously accomplished young physician, she has moved quickly on her belief that the OMA must defend physicians when they are attacked, and defend patients when their care is compromised.  This was most recently seen in her quick reaction to the strike in Thunder  Bay.  Whether in the news, or her personal blogs, she has repeatedly been speaking out on issues where physicians voices are compromised.

While there is still much more to be done at the OMA, it’s refreshing to see that the organization is speaking out on areas like this.  It means I have huge shoes to fill next year, but I can honestly say I’ve been inspired by the actions of the last two Presidents.

 

“Smokey” Thomas Fails His Members

Authour’s Note:  Once again, I would like to state that while I am President-Elect of the Ontario Medical Association (OMA), I have not spoken with any of the Family Doctors in Owen Sound about this situation.  I did email them to ask permission to write this.  All of my thoughts are strictly based on reports in the media, and news releases (all of which are hyperlinked).

Last week I had suggested that Ontario Public Services Employees Union (OPSEU) President Warren “Smokey” Thomas should change his approach on how he dealt with physicians in union disputes.  Sadly, Smokey has doubled down on his tactics.  In doing so, not only has he utterly and completely failed his members, but he risks endangering health care in Owen Sound.

In Owen Sound (population ~ 21,000) there are 22 family doctors who have organized themselves into a Family Health Organization (FHO).  The FHO is a fairly common payment model that consists essentially of a salary and performance bonuses.  Like all other payment models the FHO models experienced years of deep cuts to their budgets during the desultory tenure of Premier Kathleen Wynne.  Cuts to physician payments, mean cuts to patient services.  Hence, the FHO focused on controlling expenses as best it could.

The staff at the FHO chose to unionize (which is their right) but unfortunately chose to do so under OPSEU, and became Local 276.  OPSEU and Smokey have absolutely no experience in dealing with intimate small office settings, and the necessary collegiality that is essential to providing high quality front line care.  As a Family Doctor, you MUST trust everyone from the receptionist, to the nurse and even the cleaning staff.  While disagreements occur, and are often healthy, the trust cannot be compromised, or patient care will suffer.

Smokey and OPSEU’s lack of experience showed almost immediately. Their bargaining team agreed to a contract and recommended it for approval to the FHO staff in May.  That’s right folks, OPSEU actually reached an agreement.  But the agreement was rejected by the FHO staff, a clear repudiation of OSPEU’s leadership.

This appears to be when Smokey went off the rails.  He (and OPSEU) could have taken a hard look at themselves and asked a simple question – “How could we be so out of touch with the members we represent, to have endorsed a deal they rejected off hand?”. But they didn’t.  Instead, in what seems to be an effort to prove to their members that they really are relevant, they doubled down and started hurling insults and threats.   Doctors were “punch drunk with greed” they screamed.

The FHO staff then went on strike, and the results appear to be disastrous for them.  Firstly, OPSEU should have told them that doctors office are not factories that make sprockets and cogs.  They provide essential medical services and they cannot be shut down.  The physicians continued to work, with legally allowable replacement staff (albeit at reduced levels).  All a picket line would do is harass patients, and that won’t win you public support.

Reports of harassment and even a serious medical event involving a replacement worker appeared, although it’s unverified.  Again, instead of stopping to think “What exactly are we accomplishing here?” Smokey, doubled down, increased his insults to physicians, demanded that the Health Minister and Owen Sound Town Council get involved (he failed miserably).  He also made a ludicrous allegation that physicians were “private and for profit”. Has Smokey not read the Canada Health Act?  Physicians haven’t been private since 1984.

Apparently, ten of the 30 FHO staff got wise to what a lousy job Smokey and OPSEU were doing, and actually quit their jobs.  Yet another opportunity for OPSEU to reflect on their own failures as a bargaining agent.  But yet again, Smokey lashed out, this time by asking the College of Physicians and Surgeons of Ontario (CPSO) to get involved.

Let’s be clear, the letter written by OPSEU is a collection of hearsay without naming any one physician. As such, it cannot possibly be investigated by the CPSO.  If they were to do so, it would diminish the already poor standing the CPSO has in the eye of most physicians, and would send a pall over the entire profession. They would almost certainly faced increased calls from physicians to lose self-regulation if there was anything other than a cursory “thank you, but this is outside of our purview” type response.

But the reality also is that a letter to regulatory body like this takes you beyond any hope of restoring trust in your team.  It’s the one thing that has potential to destroy careers. It’s the one action that essentially screams “irreconcilable differences”.  By going down this road, in what seems to be a desperate attempt to prove his worth, Smokey has caused a toxic meltdown to the point where there is no hope of a resolution.

The members of OPSEU Local 276 would do well at this point to really ask themselves if this is the kind of leadership they signed up for.

Nothing Wrong With Advocating For Physicians

Authour’s note:  This opinion piece of mine was published in the Medical Post.  However, many physicians are unable to access that as you need a dedicated account.  I’ve reproduced it here.

The Canadian Medical Association (CMA) has been embroiled in controversy this past year.  It first started with the announcement of “Vision 2020”, the new strategic plan for the CMA. What’s the first priority of the plan? “Consistently bring a patient perspective to the work of the CMA.”  The second priority?  “Engage in courageous, influential and collaborative dialogue and advocacy.”

This all sounds nice, and politically correct and oh so socially conscious.  Except for one thing.  The CMA is supposed to represent physicians and their needs.  That’s the whole reason for its existence.  Instead, physician representation is third on the priority list, and even there, it’s couched in phrasing like “based on empowering and caring for patients, promoting healthy populations and supporting a vibrant medical profession.”

From the perspective of the CMA’s leaders, I suppose the needs of the general membership don’t really matter.  The recent sale of MD management to ScotiaBank has provided the CMA with a significant amount of revenue.  So much so that they likely don’t even need members anymore.  It’s worthwhile noting that the first $15 million from the sale has been earmarked for a building for health care innovation, as opposed to, you know, a program to look at the alarmingly high burnout rates of physicians.  Certainly the changes made at CMA Governing Council (no more motions to direct the organization) prevent the CMA Board paying attention to silly little things, like the duly elected representatives of physicians across the country.  (NB – it would be unfair of me not to acknowledge that at least the General Membership will be able vote on all the Board members for the CMA.  However, I’m curious to see what the criteria are for becoming a candidate for CMA Board).

There is similar pressure to advocate for patients and health care policy, being placed on the Ontario Medical Association (OMA), particularly on social media.  Recently the OMA has been asked by various physicians to:

– sign letters opposing the separation of children from parents of migrants

– condemn the changes to sexual education curriculum made by Premier Doug Ford’s government

– speak out against the pause to Vaping rules, also made by Doug Ford’s government

– express concerns about the health care for trans gender patients

– and a bunch more.

There are merits to all of those causes (the separation of children from parents is the one I feel strongest about – it’s just child abuse). There is also the argument that physician’s organizations should use their authority to advocate for social issues, as it increases our standing in the eyes of the public and makes us “leaders”. This enhanced standing will supposedly help us when we advocate for ourselves.  The cynics, especially those of us burnt by the previous Ontario government will strongly disagree with this.

But here’s the thing, there are so many good causes out there to advocate for.  And they will keep coming.  How should the OMA, which unlike the CMA, continues to need broad member support, choose?

There is already disagreement about vaping rules/sex ed curriculums and so on.  What happens when the OMA is presented with information about the poor health care Rohingyan women receive?  Or the damage the contaminated water in Flint Michigan has caused?  Or if you want controversy, how about the malnutrition and mental health issues suffered by Palestinian children?  The OMA is supposed to represent 40,000 members with a diverse range of views, not just those who are motivated by one particular issue.

Many Provincial and Territorial Medical Associations (PTMAs) offer media training and advocacy courses.  The OMA for example, has long been asking physicians to become advocates.  Perhaps rather than criticizing on social media, those who feel passionately about various issues can receive the training to allow them to become leaders in their areas of interest.  They can then directly get their message across to the public and work for whatever their cause is.  They are still doctors, and they will still be seen in the public’s eye as doctors taking a lead on health care issues.

As for the PTMAs is it really too much to ask that they focus on membership advocacy first and foremost?  There is absolutely nothing wrong with advocating for meaningful action on high burnout rates, fair contracts and improved working conditions with less interference from bureaucracy.  It’s what these organizations are supposed to do.  The simply reality is that you cannot have a high functioning health care system without happy, healthy and engaged physicians.  Surely advocating for the same is not unreasonable.

Can Helen Angus Save Ontario Health Care?

Health Care in Ontario has been in a state of crisis for many years now. I’ve practiced Family Medicine for 26 years, and I’ve never seenwait times so long, nor have I seen such a dismal moodamongst health care providers. Clearly, a major transformation of how health care is delivered needs to occur.

Ten days ago we saw a new government in Ontario. By glancing at twitter feeds and media reports, the biggest news in health care seemed to be about the appointment of new Health Minister Christine Elliott. Minister Elliott is an excellent person and will bring the kind of common sense to the Health Ministry that was completely absent during the Kathleen Wynne/Eric Hoskins years. BUT, the most important announcement last week (and one widely ignored by the media) was actually that of Helen Angus to role of Deputy Health Minister. She takes over for the widely dislikedBob Bell, who suddenly retired once the Liberals lost the election. Curious timing that retirement, considering the post is supposed to be apolitical.

You see, the Health Minister is the person who produces high-level strategic directions for health care service delivery. But it’s the Deputy Minister who actually carries out the grunt work and implements the processes to carry on these strategic directions. Having been part of many organizations, I’ve seen bureaucrats both greatly benefit – and greatly hinder – the implementation of these strategic directions. It will be up to Ms. Angus to do the heavy lifting, and transform the Health Care system.

Is she up to it? Her bio shows she has been heavily involved in health care for many years, including various roles at the Ontario Renal Network, Cancer Care Ontario, the Ministry of Health and others. She was actually the interim Deputy Minister of Health for five months, until the aforementioned Bob Bell was hired. Then she suddenly left the health care field altogether to help out the Ministry of Citizenship. (More curious timing there). So with that experience there is a sense that she will bring a steady hand to the position.

Based on her speech to the “Breakfast with the Chiefs” she also has the ability to “speak the language” of health care bureaucrats. Phrases like “shared accountability”, “transformation secretariat”, and “stream of work” fluidly roll off her tongue. Personally, I find these phrases vapid and incomprehensible (eHealth Ontario for example is not “still a journey” as she states, it’s a disaster). However, this kind of verbiage is needed to communicate with other health care leaders, so I’m glad that she is able use it.

What does she truly believe in as far as health care goes however? Assuming she wasn’t just towing a political line, it also appears from her speech that she recognizes the need to transform health care and break down the various silos in health care. Silos refer to the fact that we have a bunch of different organizations in health care, e.g. hospitals, home care, your doctor’s office, that operate independently, and often not in a co-ordinated manner.

When I was the Health Links lead physician for South Georgian Bay, I recall Deb Matthews referring to Ms. Angus as “the silo-buster”. Ms. Angus of course, never got to work on that because as mentioned, she suddenly left health care altogether when Bob Bell became the Deputy Health Minister. Bell, under the guidance of the pitiful Eric Hoskins and the forlorn Kathleen Wynne never got around to busting silos. Instead the three of them thought it would be better to get into a toxic, pernicious, and vexatious relationship with Ontario physicians. We all saw how that worked out.

Ms. Angus spoke of the need to make health care more patient centred, and improve access for patients. Part of that will require a significant streamline to Ontario’s bloated health care bureaucracy. Part of that will require she forces a dollop of common sense down her bureaucrats throats (why does it take two years to make a change when everybody agrees something is a good idea?).

The good news is that she appears to have some cover in that current Premier Doug Ford wants to run a fiscally responsible government and reduce bureaucracy (though by natural attrition as opposed to layoffs). More good news is that the Ontario Medical Association (with whom she must partner if any transformation is to occur), recently decided to temporarily suspend the arbitration process they are involved in, in order to hear the new governments position. As a gesture of good faith, they didn’t even ask for a concession for this move. If she can help to repair the noxious relationship created by the Liberals, and give doctors a meaningful say in how health care is delivered, she will be able to move more effectively in her goals.

It’s a big job ahead for her. For the sake of all Ontarians I wish her well. Our health care system is too important to be allowed to flounder any longer.

Good company in a journey makes the way seem shorter. — Izaak Walton

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