Health – Page 2 – justanoldcountrydoctor

Dear Sylvia Jones, Here’s How to Make Health Care More Convenient…

Congratulations on winning the last election and being re-appointed health minister. The health ministry is the toughest job in government. I sincerely mean now, what I wrote before, that all of us should hope you are successful. Ontario deserves the healthiest possible population.

Of course, that still won’t stop me from giving you advice (whether you want it or not)……

I’ve noticed that you place a really high value on making sure that health care is “convenient.” Your government even calls the overall program “A Plan for Connected and Convenient Care.” Your talking points in the press always mention “convenient.” Even the second major outline for health care uses that word.

I would suggest that rather a lot of your health care platform is based on making people happy by giving them what they want and making things easier for them. For example, your boss, premier Doug Ford, when talking about the expanded scope of practice that allowed pharmacists to prescribe treatments for minor ailments focused almost exclusively on the fact that it was one of the most popular things your government has ever done. The public was satisfied, so it must be a good thing.

Now I appreciate that you don’t have a health care background. If you did, you would know, that convenient health care, and patient satisfaction in health care, actually have a negative correlation with health care outcomes. Essentially, when patient satisfaction with the health care system goes up, the health care outcomes get worse. A study published in Medscape showed that focusing on patient satisfaction lead to 12% higher hospital readmission rates, 9% higher health care costs and 26% higher mortality rates.

Basically, focusing on convenience and satisfaction in health care costs more, makes people sicker and kills more people.

However, at this point, I doubt that I can get you to shift away from this philosophy. So I have an idea that will make health care much more convenient for people. Something that will reduce the amount of travelling back and forth that people do, and will allow them to quickly and easily get their health care needs taken care of in one spot.

It’s time for you to amend or revoke regulation 114/94 under the 1991 Medicine Act. This prohibits physicians from selling medications to patients. My sincere thanks to OHIPs former lawyer, Perry Brodkin, for pointing this out to me on X.

How will this be convenient? Well, right now, when a patient goes to see a physician for, let’s say high blood pressure, the patient will get assessed by their family doctor, and based on their medical history, an appropriate medication will be chosen for them. They will then drive to the pharmacy with that prescription. The pharmacy will take however long it takes for them to fill out their prescription, and after a period of waiting, the patient will get their needed medication.

By allowing physicians to have their own dispensary, a patient will now go to the physician’s office, and if a prescription medication is deemed necessary, they can just purchase it from the physicians office right then and there. It saves them an extra drive, and perhaps even parking lot fees depending on where they go. This will, of course, be extremely convenient for the patient.

What’s that you say? Isn’t this a conflict of interest? I mean, if a physician is now able to sell the drugs after making a diagnosis, wouldn’t it encourage physicians to prescribe more medications?

Um, can I ask why that didn’t seem to bother you when the pharmacists were allowed to expand the scope of their practices by you? Pharmacists now make an assessment for certain minor illnesses, get paid to do that by the government, determine what in their opinion the right treatment is, and then sell the patient the drugs at a profit. (This is what naturopaths and some chiropractors do as well, but that’s a whole other story.)

What’s that you say again? Pharmacists have to abide by a certain code of conduct from their college. They are bound by their code of ethics to act in the best interests of their patients. Um, ok. You do know that physicians also have a college that we answer to, right? You do also know that physicians also have a code of ethics? That we all took an oath to do no harm to our patients?

Might I ask exactly what the difference is between these two scenarios?

Of course, while most patients would be happy for this convenience, I imagine not everyone will be happy. I suspect (Shoppers Drug Mart bigshot) Galen Weston would be quite annoyed if you did this. But hey, look at the bright side, at least you won’t have to deal with some miserable crotchety old country doctor spouting off in the media wondering who exactly the health minister was in this province.

Galen Weston, of Shoppers Drug Mart and Loblaw fame.

Look, at the end of the day, for me, it’s health care outcomes that matter the most. I want patients to have the best possible results for themselves and health care as a whole in Ontario. But if you are going to insist on “convenience” then at least do it in a way that’s fair to all of the health care professions.

Change or amend the 1991 Medicine Act to make life a little easier for the patients.

Yours truly

An Old Country Doctor

P.S. While you’re at it, don’t forget to direct your OHIP Bureaucrats to not seek repayment from Dr. Elaine Ma. Don’t think doctors in Ontario have forgotten about this situation.

Unrelenting Bureaucracy is Killing Health Care (and Canada)

Canadians are currently dealing with the dizzying spectacle of Donald Trump’s tariffs against our country. On again? Off again? Delayed? Doubling? I’ve personally gotten seasick trying to keep up with whatever tangerine Palpatine is thinking.

U.S. President Donald Trump – aka the Tangerine Palpatine

However Canada’s response to this (and the nonsense about us becoming the 51st state) has frankly been quite lacking. Yes, it’s great to see Canadians being able to fly the flag with pride, especially after the miserable co-opting of the Canadian flag by the freedom convoy types, who likely themselves were Donald Trump supporters. (How’s that working out for you guys now?) Yes #elbowsupCanada is a wonderful approach to take and a great mantra going forward, particularly with how intertwined hockey is with our nation. (Quick reminder: Not only do we win Olympics, we win Four Nations Cups as well).

BUT, for all the outcropping of (absolutely warranted) national pride – our governments – outside of launching retaliatory tariffs, haven’t done anything to fix the systemic problems in our economy. For example, getting rid of domestic trade barriers and having free trade between provinces would provide a boost of up to $200 billion dollars to our economy, but seemingly no action on this yet.

Even more importantly and what’s long overdue, is an absolutely necessary look at the bureaucracy and impediments that many businesses face in trying to contribute to our economy. Let me talk about a personal experience (and no disrespect intended to the good people on staff in my township).

About 10 years ago, our community had clearly outgrown the medical centre. Some poor sap was put in charge of expanding it. (Guess who.) I had to deal a myriad of problems of putting an addition on our medical centre. Here’s a couple of examples of what I dealt with.

As per policy, the township requested that we provide an engineered site plan. The reason for this was to assess water drainage requirements. While on the surface this makes sense, all the engineered site plan was going to tell us what size of culvert to put on our property for water drainage. The estimate for the site plan was about $15,000.

A sad, lonely culvert, passing its life away draining water…

However, it turns out there were only two sizes of commercial culverts for our project. A big one and a small one. The big one cost $500 more than the small one. Being well-versed in the obstinacy of Ontario Health’s bureaucrats, but somewhat naive in the inflexibility of municipal bureaucrats, I offered to simply put in the bigger culvert right from the start in exchange for waving the engineered site plan.

Those discussions went as well as my less naive readers will expect. The site plan wound up costing $17,000, and it told us that we had to put in the big culvert.

Want more? The township requested a $250,000 letter of credit or certified cheque prior to approving the expansion of the building. My initial reaction was somewhat negative to this request, but upon reflecting, I did realize that it made sense. The request was put in place in case a builder started a project, ran out of money before they finished the project, and left a hole in the ground. The money would then be used to pay to clean up the mess they made.

I still grumbled about the fact that the township was making long term doctors who were clearly invested in the community do this, but I have to concede that it was fair.

The bank informed me there’s some complex fee formula for a letter of credit – and it would have cost $5,000. I asked them for a certified cheque, and it turns out banks don’t do that anymore. However, they were willing to issue a bank draft and the fee for that was $50. Obviously, I got the bank draft instead.

When I went to the planning office however, I was told this was unsuitable. The contract we signed specifically asked for a Letter of Credit or Certified Cheque and I had presented neither. Therefore we had not met the terms of our contract and the project would come to a halt. The staff person did offer to take this to the planning committee, and six weeks later they decided this was ok.

Is this me just griping? Nope – in fact his is happening all through health care and businesses in Canada. I recently spoke to the owner of a Nursing Home. His home had been approved on a “fast track” for a new build based on the dire shortage of nursing home beds in Ontario. I asked when the facility would be built and he just laughed. Apparently “fast track” means that there will “only” be 30 months of paper work (!) before the shovels go in the ground and he hopes it will be completed in 5-6 years!! I’m guessing this “fast track” must be on Toronto’s Eglinton LRT line….

A sad, lonely train on Toronto’s much, much, much delayed Eglinton LRT line

Want more? Just look at the saga of my local hospital, the Collingwood General and Marine. We’ve known for almost two decades that it’s far too small for the community. Heck the community has been asking for a new hospital since the early 2010s and finally got approval on phase 1 (of 5) in 2016. And 9 years later (!) we are at phase 3. The “hope” is that the new building will open its doors in 2032 – 16 YEARS after it was absolutely clear a new hospital was needed immediately.

This problem is not restricted to the health care sector of course. The Financial Post had a piece in 2019 (!) about how these rules are affecting multiple industries. Not only are we not building critical infrastructure in a timely manner because of an inability to cut the bureaucratic bloat, but it’s stifling private businesses as well. The Canadian Chamber of Commerce pointed out that the “ease” of doing business has gone from fourth in the world in 2006 to 53rd now, and this impedes economic growth and investment.

New Prime Minister Mark Carney is off to Europe this week to build trade and strengthen relations. Nothing wrong with that, we need reliable trade partners in the future. BUT, we face an unhinged, hyper volatile situation with our neighbours to the south RIGHT NOW. It seems to me there is no better time than now to drop intra Provincial trade Barriers and right size the bureaucracy allowing for businesses to grow and thrive more easily in Canada. As for health care, the right time was 10 years ago.

Health Care in the Ontario Election: Lots of Sound Bites, No Strong Policy

Last week, I had the opportunity to talk to Greg Brady, on his 640 am radio show, Toronto Today. The episode is on Spotify and, if you are in need of a great cure for insomnia, you can catch me starting from about the 19:30 mark:

Six and half minutes is not enough time to discuss health care in Ontario. Neither is a 1,000 word blog, but that won’t stop me from trying to expand on some of my thoughts.

The first and most prevalent thought I have is disappointment in ALL of the political parties for how they have addressed health care so far. Everyone on the front lines of health care has known for a least a decade that we need bold transformative changes in how health care is run and delivered in Ontario. Probably all of Canada.

And yet, the four would be Premiers all fail to outline a plan for such transformation. Instead, they have all resorted to that age old political vote grabbing stunt of saying “Let’s just throw more money at the problem” without actually reminding you that the money is going to come from YOUR pockets and is going to be, frankly, poorly spent.

The Conservatives hired Dr. Jane Philpott to oversee a spend of $1.8 billion in a plan to connect everyone with a “primary care provider” in the next few years. As I’ve written before, that plan, through no fault of Dr. Philpott, who I have a great deal of respect for, is doomed to failure.

The Conservatives did not start the downfall of family practice in Ontario (that was the miserable Eric Hoskins/Bob Bell duo during the wretched Kathleen Wynne years). But they sure haven’t done enough to fix the mess they inherited. Economist Boris Kralj, PhD, recently showed in the Medical Post that Ontario lost 238 family physicians in 2022/23 – the biggest loss of any province.

The Liberals for their part want to spend 3.1 Billion dollars. At least they promise everyone a family doctor and not a “provider” (and yes, there IS a difference, a BIG one between the two). However, their plan amounts to spending $1.3 billion more than the Conservatives. Spending more without changing things seems naive at best.

The NDP promise to recruit 3,500 more doctors, promise family doctors for everyone, cut red tape, establish a “Northern Command Centre” for health care (that’s actually a good idea) – all for the low low price of only $4.1 Billion dollars, a billion more than the Liberals.

The Green Party promises are actually the most detailed I could see, including lots of goodies, like recruiting more doctors, building more nursing homes, increasing nursing student spots, hiring 6,800 personal support workers and more. There is only one thing missing from the proposal (at least on their website). How much this will all cost YOU, the taxpayer.

Ontario spends $81 billion in taxpayers dollars on health care. Rather than look to see if that money is being spent wisely, and looking to transform health care, all the political parties are simply giving us sound bites. They promise to spend $83-$85 billion on the same failing system, without looking at changing things. Because spending more inefficiently will surely fix things.

OK Smart Guy – What do YOU Think Should Be Done?

Glad you asked dear reader, glad you asked. At an absolute minimum I’m looking for a party that has the political courage and wisdom to do the following three things.

First, A complete hiring freeze on all bureaucrats in health care, including not replacing those who retire, or leave for other reasons.

Currently Ontario has 10 times as many health care bureaucrats per capita as Germany. That’s too many. This means that any meaningful suggestions for change have to go through so many bureaucrats that the whole system is plagued with paralysis by analysis. Time to trim the fat.

Second, ensuring one, and only one, patient app that every resident of Ontario has, which will have access to all their health care data, and allow them to share this with the health care specialist or facility of their choice

Ontario is a digital health nightmare. Your health information often times can’t be shared if you go from one hospital to another, or one doctor to another. There are multiple inefficiencies and unnecessary repeat tests because of this mess and it should never have been allowed to occur.

It would be too expensive and too time consuming to force every health care facility to use the same electronic medical records system. What can be done however, is to force all the systems to integrate with ONE patient app. This will ensure a common standard, and moreover will allow a hospital you happen to be in, to access your out patient information (with your permission) which just doesn’t happen now.

Third, ensuring strong family physician representation at the board level of the Ontario Health Teams.

There is a lot of talk about the benefits of team based care. As someone who views one of his proudest achievements to be the founding Chair of the Georgian Bay Family Health Team, I would agree with this. The current plan for Ontario Health Teams does have merit. BUT, in order for these teams to succeed, they need strong family physician leadership at the GOVERNANCE level. That’s right, you need to put doctors (and more than just a token one) on the Boards of these teams and ensure the teams are led by them – for best clinical outcomes. I don’t see that in the plans.

Final Thoughts

My usual followers will know that I generally vote on the conservative side of the political spectrum (de gustibus non est disputandum). However, I’ve been frankly disappointed that the current Conservative government has been anything but conservative. Sadly, the other parties are really not offering the kind of transformative solutions we need in health care either. I firmly believe that we should all vote in elections, and I certainly will, but for now, call me an undecided old country doctor.

Re-Post: Hoskins Won’t Survive The Mess He’s Made Of Ontario Health Care

NB. The following is a re-print of a blog I wrote for the Huffington Post, published originally on July 10, 2017. It’s being republished here mostly for my own record keeping.

Recently, one of my medical school classmates (now a cardiologist) was awarded the Society of Thoracic Surgeons top rating for patient care outcomes. A great honour for her, and well deserved. Unfortunately for the rest of us, she practices in South Dakota, one of the many physicians who left Ontario during the protracted battles with Ontario Governments in the 1990s.

Back then, as I mentioned in my first blog, many health ministers continued to insist that physicians in Ontario were the highest paid in all of North America. Yet we lost physicians in droves. The reality is that while physicians wanted to be paid a fair wage (who doesn’t?), what they really wanted was to have a say in how health care was delivered and be able to advocate for their patients.

So when the then Ontario government of Bob “Super Elite” Rae made unilateral decisions about health care, physicians left for jurisdictions where they were paid less (according to then Health Ministers Frances Lankin and Ruth Grier). But at least they had a say in how health care was delivered.

I mention this because it appears that current Ontario Health Minister “Unilateral Eric”Hoskins and his Deputy Health Minister Bob Bell have been unable to grasp this fundamental concept. Hoskins (and, to a lesser extent, Bell) have based their whole political strategy on portraying the dispute in the media as one of doctors wanting endless sums of money. If only the doctors would take less, the health-care system would improve. They appear unable to grasp the fact that doctors VALUE the ability to advocate for their patients and contribute to health care decision making.

From a purely political point of view, the strategy had some benefits for Hoskins and Bell. They were able to pass both the Patients First Act and the Protecting Patients Act. There was muted public response because they were able to portray physician opposition to these Acts as physicians protecting their incomes. The fact that the Patients First Act does nothing but increase bureaucracy and that the Protecting Patients Act actually violates Charter Rights of all health-care workers, and will likely be the focus of a Charter challenge, meant nothing to Hoskins and Bell. Good PR in the face of mounting, repeated, ongoing evidence of the collapsing health-care system was all they wanted.

Surely the Hoskins/Bell duo thought their troubles were behind them when the OMA ratified the BA framework. Not so.

It must therefore have come as a shock to Hoskins and Bell when, after giving Physicians Binding Arbitration (BA), physicians actually increased their attacks on the Liberal Government mismanagement of the health-care system. Now to be clear, giving BA is not the same as awarding a contract. The Ontario Medical Association still has to negotiate a contract for physicians.

But central to Hoskins and Bell’s way of thinking was that all physicians cared about is money. And the spectre of BA does force both parties to negotiate fairly.

Also in fairness, it’s pretty evident that Hoskins himself didn’t want to give physicians BA. Not only did he deride physicians for asking for it and fight it in cabinet, but when the Ontario government sent a press release indicating they want to return to negotiations with the OMA with the first order of business being to develop a BA framework, it came from the premier’s office, not Hoskins’ office.

Regardless, surely the Hoskins/Bell duo thought their troubles were behind them when the OMA ratified the BA framework. Not so.

Wait Time Series: Cataract surgery patients are finding themselves on longer #waitlists as funding fails to meet demand in Ontario. #ONpoli pic.twitter.com/Nh466RND1k

— Ont. Medical Assoc. (@OntariosDoctors) July 5, 2017

Since then, the OMA has become even more aggressive in its attacks on the Liberals. Have a look at their Twitter feed where they attack wait times for cataract surgery and joint replacement surgery.

Also, a grassroots group of doctors have now begun tweeting multiple barbs at the Liberals. Saying that doctors are required to put the pieces of health care together, they’ve used inventive and creative images to drive home the point that the Liberals don’t know what they are doing in health care.

Finally, OMA President Dr. Shawn Whatley openly wrote in his blog that physicians need to be champions, not doormats, and fight for health care for their patients. Surely poor Hoskins and Bell never expected this when they actually gave the OMA a path to a fair contract via BA. Goes to show you just how much they misjudged physicians’ desire to advocate for their patients and for a fair health-care system for all of us.

Hoskins and Bell are now, as the old joke goes, officially “post turtles.” This joke compares a (usually inept) politician to a turtle balancing on a fence post. You know he didn’t get there by himself, he doesn’t belong there, he doesn’t know what to do while he’s up there, and you just want to help the poor thing get off the post.

Ontario Premier Kathleen Wynne basically has little choice now. Hoskins and Bell are just too easy targets for the mess that they’ve made of health care and the way they’ve badly misread physicians passion for protecting their patients. The differences are irreconcilable.

Hoskins is the easier of the two to deal with. Wynne needs to shuffle her cabinet and move Hoskins on to minister of sanitation or something.

Bell, being an employee, has certain rights and can’t just be fired. However, the anonymous surveys done by Quantum Transformation Technologies indicating how unhappy his own bureaucrats are should be enough evidence for Wynne to order a formal administrative review of the senior management team at the ministry of health. Maybe they can be salvaged with administrative coaching.

But what’s clear is that as the health system fails, Wynne needs front line physicians to help put its pieces back together. Wynne needs to regain their trust. The way to do that is to bring tangible change to the leadership of the ministry of health.

Stories From a Failing Health Care System

By now we’ve all seen multiple new stories of the failing health system in Ontario. It would not be inaccurate to suggest that our health care is now in a permanent state of crisis. But most of these stories deal in numbers that seem almost abstract. For example 2.5 million without a family doctor. 30 weeks to see a specialist from the time of a referral from your family doctor. Hospitals at 134% capacity.

They all are awful stories -but what does this mean on a human level? Do these numbers actually tell of the suffering of patients on a human level? Today, let’s look at what some of my patients (all anonymized) are going through.

Patient A

Patient A had a persistent cough for a number of months despite my attempts to treat them with the usual therapies (puffers, prednisone, antibiotics and a Hail Mary pass of trying to see if acid suppressants would help). I recently attended a Continuing Medical Education seminar on Interstitial Lung Disease (ILD). ILD is a bit of miserable new condition that is very difficult to diagnose and even more difficult to treat.

I ordered a chest xray which was done on July 29 – and concern was raised that this might be the diagnosis. A high resolution CT scan (gold standard for diagnosing ILD) was ordered by myself to follow up on this – and this could not be done until Sep 10. This unfortunately confirmed ILD was the correct diagnosis.

One of the things that was evident from the conference I took is that time to see a specialist for ILD was paramount. There is no cure for this illness. But timely treatment can salvage lung tissue and improve quality of life. A referral was immediately made to a Respirologist.

Six days later, I got a note from the first Respirologist, who refused the consult. Basically he was too busy and asked me to find someone else. A second Respirologist was sent a referral on September 16. On October 25, I got a reply, also refusing the consult. A third referral was sent and the patient was finally seen on Jan 5. But for five months, their lung tissue continued to deteriorate and worsen.

Patient B

Patient B is 8 years old. Has had a number of viral illnesses, mostly upper respiratory in nature. But all of them have been associated with wheezing. She has responded nicely to puffers, and I wanted her to get assessed for asthma and get some asthma teaching for her parents – help them understand what things to avoid and so on.

I referred them to the excellent paediatrics group in Barrie (our local referral centre). Unfortunately, I got the following message from their staff (and I understand why, but it’s heartbreaking):

“Due to large influx of referrals Barrie Pediatrics is booking into late fall 2025 – early winter 2026.”

This is of course, not their fault. But for children with health issues, many of whom will deteriorate without specialist care, this is devastating.

Patient C

I saw them in my office on February 8, 2023 with what clearly seemed to be sciatica. Because there were no red flags – I tried anti-inflammatories and physiotherapy first. After a month or so this did not improve, so I ordered an MRI. This was not done until AUGUST of 2023 and it confirmed that may patient had a left L5/S1 disc herniation in his spine, which was causing his sciatica.

Now six months with no relief of pain with conservative measures, the standard would be to refer him to a neurosurgeon for assessment. Which was done. Unfortunately, we got no word back from the neurosurgeon. In fact in September and October of 2023 – the patient called my office to check to ensure that the referral had been sent.

By June of 2024 (!) he was in so much pain that I wound up referring him to a pain clinic for control of his back issue. In November of 2024 (!) he finally saw the surgeon who agreed with my diagnosis, and that my patient was a good candidate for surgery. But by now the MRI was felt to be too old – and – another one was ordered (still not done yet). And of course. my patient continues to be in chronic daily pain.

I could tell many more stories. I could probably write two dozen blogs just listing the difficulties I have had accessing psychiatric care for my patients. But by now I hope you get the point. Behind each number you may read about in the news (12 hour wait time in Emergency! 9 months to get diagnostic testing! 118% average overcapacity in hospitals!) – there are a large number of real human beings. People who are in constant pain and whose health is deteriorating faster and more than it should.

Hopefully you can spare a thought for the individual patients and what they are going through as our health system continues to collapse.

Sunday Snippets: Nov 24, 2025

Another in a weekly series of brief snippets of health care stories that bemused, intrigued and otherwise beguiled me over the past week along with my random thoughts on the matter.

Item: Dr. Sarah Giles writes in the CBC about how she was forced to cut her hours because of the burnout.

My thoughts: Kudos to Dr. Giles for talking so openly about this. Alarmingly few of my colleagues are willing to talk about burnout and how the system is affecting them. Instead they suffer in private, and that’s not healthy for them OR the patients they serve. It’s an important story that needs to be told over and over again.

Item: “Involuntary medical treatment” for people with addiction issues seems to be all the rage. A great article in the “Conversation” shows that this won’t solve anything, and in fact will make things worse.

My thoughts: I really can’t believe we are even discussing this. It has been well known for…..well forever, that people will not get better unless they want to seek help. We have to focus on making seeking help easier, not forcing them.

Item: The always excellent Dr. Katelyn Jetelina, who most of my colleagues know as a superb voice of reason and information during the height of the Covid pandemic, writes about her feelings now that RFK junior has been nominated to lead Health and Human Services in the United States.

My thoughts: My heart goes out to her and all the hard work staff who have tried keep us all safe during the pandemic. They deserve better.

Robert F. Kennedy Jr., a leading American Anti-Vax conspiracy theorist, now tapped to head Health and Human Services in the United States

Item: TV Ontario had a segment suggesting that foreign trained physicians could help tackle Ontario’s physician shortage.

My thoughts: I’ll shout it out again, we already have enough family doctors in Ontario who are already licensed to practice medicine in this province and are familiar with the Ontario Health Care system. The number is approximately 6,000 or so (see the graphs in the linked blog for details). Can we just not make it easier to practice family medicine instead??? If we can get even 1/3 of those doctors already in Ontario to start a practice, we would end this crisis.

Item: Great article on the physician gender wage gap in Health Debate. Clearly shows that the gap is real and needs to be corrected.

My thoughts: One of the best accomplishments of the OMA Board when I was on it was to publish the gender pay gap report. It was arguably too late, but I believe we were the first PTMA to discuss this and to use that as a basis for future negotiations work. While I’ve had some issues with how negotiations have been handled since, I am quite comfortable in saying that positions of the OMA in negotiations would take this into account and that there is likely to be funds demanded to narrow this gap. The blame for the fact that there has been no progress on this lies mostly at the feet of the Ministry of Health. We don’t have an agreement yet on how to divide the arbitration award – and that means the Ministry is not responding to OMA proposals that would close this gap. Shame on them.

Item(s): Alberta announced that it hiring a large number of nurse practitioners to become “primary care providers” to patients who don’t have a family doctor.

My thoughts: The National Health System (NHS) in Britain is under fire for the fact that it too tried to replace the work done by fully trained physicians, with staff who were likely well intentioned, but had less qualifications. It turns out there is significant risk to this, and likely a markedly increase cost in providing health care. The article “My wife died because the NHS used cheap labour” should be, in my opinion, required reading for any politician/health care bureaucrat who thinks they can provide better care by using less trained people.

That’s all for this week. Back next week (probably) with more.

Bureaucratic Vertigo in Ontario’s Home Care System

Bureaucratic vertigo in Ontario’s home care system, exacerbated by ineffective reforms and rebranding, has led to chaos and service stagnation, necessitating genuine engagement with frontline providers for meaningful transformation.

Dr. Merritt Cade (not their real name) is a concerned and experienced Ontario physician familiar with the current crisis in home care. Dr. Cade is worried about potential blowback from this blog that will affect their patients and so this blog is posted under a pseudonym.

Vertigo is a sensation where one perceives movement that isn’t happening. In the realm of healthcare administration, a similar phenomenon occurs—bureaucratic vertigo—an organizational dizziness that mimics change but leaves structures and systems untouched. Nowhere is this more glaring than in Ontario’s home care sector, a pivotal yet neglected component of our healthcare system.

In 2023, amid promises of reform, the Ontario government introduced Bill 135, the “Convenient Care at Home Act,” envisioning a streamlined home care service managed by Ontario Health atHome (OHAH). OHAH itself was to now be brought under the umbrella of Ontario Health, the implementation arm of the Ministry of Health. Hopes were pinned on this transformation bringing ease and efficiency. However, the reality has been a déjà vu of previous cycles of centralization and decentralization of health care structures, with patients and families shouldering the consequences.

Nowhere is the bureaucratic vertigo more evident than in the successive re-branding of home care over the last 8 years from “Community Care Access Centres (CCAC)” to “Local Health Integration Networks (LHINs)” in 2017 to “Home and Community Care Support Services (HCCSS)” in 2021, to the latest iteration, “Ontario Health atHome (OHAH)” in 2024. Meanwhile, regardless of the name used, the services provided by the home care system remained untouched.

Ontario Health and OHAH’s first substantive move—renegotiating contracts for medical supplies—illustrates how bureaucratic vertigo can lead to harmful consequences. Instead of solving issues, the new contract process disconnected decision-makers from frontline realities. The result? A severe shortage of medical supplies, medication delays, and a burden placed on already overwhelmed caregivers and families. Despite clear warnings from supply companies, these decisions disregarded frontline input, leaving healthcare providers to navigate chaos without support.

OHAH’s own front-line staff, the beleaguered Care Coordinators, were also caught completely off guard as rules regarding medications and catalogues of supplies changed overnight. Care Coordinators are the quarterbacks of the home care system, matching services to patients’ needs. What OHAH and Ontario Health did was akin to completely changing the playbook on their quarterbacks and teams, with sadly predictable results.

Despite all this, however, home care holds immense potential to address systemic challenges, from reducing ER congestion and the alternate level of care logjam to facilitating dignified end-of-life care at home instead of in hospitals. What is required is not another bureaucratic shuffle, but genuine engagement with those who understand home care’s nuances best: frontline providers. It is they who hold the practical knowledge necessary for meaningful reform.

The path forward demands that decision-making authority be shared with these healthcare professionals. Their experiences can inform policies that work in reality, not just on paper. This means abandoning the “bureaucrat knows best” mentality and embracing trust and collaboration. It means abandoning committees struck merely to check a box that says that frontline professionals were consulted when, in fact, their concerns do not meaningfully contribute to decisions made.

Furthermore, the status quo must not define future transformations. Further substantial changes to home care delivery, this time relating to the supply of equipment such as hospital beds, wheelchairs, walkers and other essential aids, was planned for rollout in October but has been delayed until January. Without a change in approach, we should expect similar upheaval when this takes place. Past failures demonstrate that superficial organizational changes do not equate to operational improvements. Genuine progress relies on a foundational renewal of leadership and strategy, prioritizing empathy, accountability, and proactive stakeholder engagement.

If we are to lift Ontario’s home care from its current crisis, change must be substantive, rooted in the insights of those who deliver care day-in, day-out. We must move beyond the spectre of bureaucratic vertigo and commit to sensible, informed solutions that truly benefit patients and families across the province. By trusting, listening to and involving the frontline, we can stop the spin and start the real work of reform.

Sunday Snippets – November 17, 2024

Another in a weekly series of brief snippets of health care stories that bemused, intrigued and otherwise beguiled me over the past week along with my random thoughts on the matter.

Item: New reports show that marijuana use is linked to thinning of brains in adolescents.

My thoughts: It’s not just adolescents. And it’s not just brains. I’ve seen a marked rise in people with significant mood issues ever since marijuana was legalized. There has also been a significant rise in people with stomach/bowel issues in my practice that all other tests turn up negative for. Patients with these issues are invariably marijuana users and the blunt reality is they won’t get better until they stop. I continue to be in favour of decriminalizing marijuana and other illicit street drugs if and only if we do it the way Portugal did it and not the haphazard way it is being done in Canada. But we really need to re-think the full on legalization of it.

Item: A survey in Medscape showed that there were two factors critical to reducing family medicine burnout. First would be to reduce the Electronic Health Record burden, particularly the number of times family physicians have to chart from home. Second would be to build stronger physician/nurse teams. Crucially, the teams need to be led by the family physician and NOT a bureaucrat or some other team member.

My thoughts: I hope this finally gets the Canadian Medical Association (which despite over $2 billion dollars in their bank account is amazingly growing increasingly irrelevant to front line physicians) to SHUT UP ABOUT SICK NOTES ALREADY. That’s not going to solve burnout (even though I like every other doctor hate doing them). To paraphrase a political slogan – “It’s the Electronic Health Record, stupid.” My second thought is that I remain extremely concerned that while I do feel Dr. Jane Philpott is well intentioned in her new role (to lead a primary care action team) – the bureaucrats at Ontario Health will sabotage her. They will see “teams help”, then create teams that have the assistant to the secretary to the aide to deputy minister’s attache for the Primary Care Secretariat’s deputy vice president run them. That will be a disaster. Teams need to be led by family physicians. Full stop.

Dr. Jane Philpott, head of the new “Primary Care Action Team” designed to give everyone access to primary care in 5 years.

Item(s): The family physician crisis in Ontario continues to worsen. Tillsonburg lost four family physicians. Wallaceburg is launching a large physician recruitment program to deal with their shortage. Brantford is taking a more hands on role to get more family physicians. Brockville is hiring a consulting firm that employs former health Minister George Smitherman to help tackle their shortage.

My thoughts: It’s sad that we are in a seeming “Hunger Games” of one community fighting another for the precious resource that is a family doctor. If only someone had warned people a crisis was coming. Oh, right.

Dr. Nadia Alam, who, like others, warned that the crisis in family medicine (and health in care in general) was coming ten years ago, and was ignored by governments.

Item: Premier Ford promises to correct the mistakes at Ontario Health at Home that led to a large amount of suffering for patients. He also stated that the people who “messed this up” will be “held accountable”.

My thoughts: I’ll believe it when I see it. When I wrote about mismanaged bureaucracy in health care (back in 2015!) I pointed out that no decision seems to get made by bureaucrats without continuously “circling back” to one committee or another. The reason I’ve discovered, is because this way, no individual gets blamed for (the very many) bad decisions made in health care. I’ve yet to see a health care bureaucrat fired – and I’ve met many who deserved to be. I really hope that the comments by Premier Ford signal a return to the old Doug Ford who promised to end the “gravy train” and famously said:

“What drives me crazy is when you have a supervisor in government, and they report into 12 other supervisors. That’s unacceptable.“

Doug Ford, Premier of Ontario for almost 7 years, and the gravy train in Ontario Heath continues unabated

Item: Male doctors are working less hours in a week than they used to. They are still working more than the average Canadian worker, but there has been an unmistakable decrease in how many hours they work

My thoughts: Finally! Proof that men are getting smarter! There’s more to life than work, and good for the younger docs – all of them – for seeking balance in their lives.

Item: A young Ontario mother died of cholangiocarcinoma (cancer of the gall bladder), after encountering multiple road blocks getting a new treatment (Pemigatnib) approved for her.

My thoughts: This story is absolutely infuriating and encapsulates what is wrong with our health care system. Look, there is no guarantee that she would have survived if she had gotten the treatment (it’s an awful cancer she had). BUT – look at all the regulatory agencies involved in getting the drug approved. Health Canada approved the drug in 2021. But the Canadian Agency for Drugs and Technology in Health said the evidence wasn’t clear. (So why then did Health Canada approve it?). Furthermore there are multiple provincial drug agencies involved, which means she could have gotten it had she been a resident of Quebec, but not Ontario (two tier medicine anyone?). It’s the bureaucracy and double speak from having too many agencies involved that angers me greatly. A wholesale streamlining of the process for medication approvals is desperately needed.

That’s all for this week. Back next week (probably) with more.

We Know How to Save Family Medicine. Why Aren’t We Doing It?

I’m honoured to have Dr. Mark Linder guest blogging for me today. I first met Dr. Linder during our time advocating against Dr. Eric Hoskins unilateral cuts to health care. He’s exceptionally well spoken and articulate . He’s a former ER doctor and now full time family physician and clinic owner. His other claim to fame is that got fired from the Kaplan MCAT teaching course after one session – which apparently was a first.

I just wrote this in a flurry this morning. I see stupider and stupider proposals from the government and from newspaper editorials. I see our new grads learn from their teachers that they need to stay away from this job. I then see the domino effect this has on recruitment, job satisfaction and reinforced by absurd government initiatives to save the system. I watch the OMA get pulled in every direction to try and please everyone. So apologies in advance -this is just my take really-and mostly to get it off my chest-not that it will lead anywhere. So thanks for reading.

The Family Health Organization (FHO) is what saves family medicine. It has done it before and it can do it again.

In 2006 something unprecedented happened. It hasn’t happened before or since. And perhaps we didn’t quite appreciate how unique it was. The provincial Liberal government, under Dalton McGuinty and Health Minister George Smitherman, introduced an upgraded payment model for Family Medicine. It built on the existing capitation based Family Health Network (FHN) model to enhance it.

What was so unique about this? It stands out as one of the only times a government has thought beyond their 4 year term to the ultimate health of their population as well as their economy down the road when they may no longer be in power. Sure, it was going to make them look good if everyone got a family doctor out of it-but it was a big expensive risk, a risk based on an assumption that family medicine was critical to the system, AND that practitioners need to be paid fairly for their work if they wish to retain these doctors in the future. A different time to be sure!

It worked. Look at the stats from 2008 to 2018. Look at how many Family Doctors gladly embraced the new system. Look how the number of orphaned patients dropped.

The system had flaws. I mean this was the second iteration of what was described as an experiment. The “outside use” enforcement rule made little sense in most cases. The calculation of capitation payments wasn’t always a fair representation of how much work it took to look after the patient in front of you. Certain “in the basket” fees were bizarre and should never have been part of the package. Doctors were actually more incentivized to send people to the ER over a walk in clinic!!! But all in all, it was a great innovation, a great idea, and saved family medicine. It also, no doubt saved the province millions in treatment dollars and ER visits as family doctors made themselves available to look after patients.

And then, In 2015 Kathleen Wynne and Eric Hoskins, the health minister at the time, effectively shut down enrollment in FHOs And that was the beginning of the end. I presume they just wanted to control the immediate budget – paying for family medicine up front meant huge savings down the road. But it resulted in a pretty big chunk of budget going out the door NOW. And the Wynne liberals didn’t have a health care crisis, didn’t heed the warnings that we as physicians laid out pretty starkly at the time, and decided, nah, we’ll just “pause” the experiment.

Which they did. And the fall out was obvious. As a clinic owner and a family doctor, I had a front row seat. The residents and new grads had all been trained in the new system, and now were unable to access it. If they wanted to work, they’d be taking a tremendous risk setting up a clinic in a Fee For Service environment using a Schedule of Benefits that had failed to keep up with inflation for 20 years. They were screwed. The aging Family Doctor population continued to retire at a predictable rate, and the aging population continued to get more desperate to find doctors with increasing difficulty.

By the time the FHO’s opened up again in 2021, it barely mattered–The reputation of family medicine among new grads had been thrashed for 6 years.
With the new rules, new grads would have to gather 6 like-minded individuals (instead of just 3 like in the old days), or find a bigger FHO that was already established and could fit them in. Not so easy. Opening up your own shop had become increasingly more expensive with post pandemic inflation, so the debt would be crippling just to get started if you wanted your own clinic. And these are graduates who already had a huge amount of debt coming out of school.

Couple this with the insane increase in administrative burden as we become more and more efficient at having hospitals and labs forward us copies of paperwork. In theory, amazing, in practice hugely burdensome, time consuming and unpaid. Arguably, if the FHO rates had increased at the level of inflation, there’d be no complaints about this additional work. But the FHO rates had more or less remained static relative to the cost of doing business. Still better than FFS, still paid a lot less than the actual market value of doing the job as proven by the lack of uptake that continues today.

The thing is: The FHO is still the answer. It absolutely needs some significant tweaks. The rates need to go up. The outside use concept needs to go. Minimum size and shared EMR requirement needs to be softened so that smaller groups can join together in nearby geographic areas. Some sort of separate funding will be essential to help clinic owners to keep up with inflation. But it still achieves by far the best mix of physician autonomy, clinic management, and long term government savings. And it’s evidence-based! We have a recent history we can look back on to demonstrate efficacy!

Other solutions, such as having lesser-trained individuals diagnosing and managing patients give the appearance of short term gains at a huge future cost as more referrals to specialists are made and more referrals to the ER are made. Another concept of having government run all clinics is clearly so expensive as to be dead at the gates-Doctors currently pay for rent, administration and their own retirements out of their incomes. It’s not great for us, but it’s a heck of a lot cheaper for the taxpayer to do it that way, and simply pay the doctors more.

I recognize that my FFS colleagues are not helped at all by an enhancement and advocacy for the FHO approach. And I’m sorry. I obviously think there’s a lot of work that could be done to improve FFS rules and individual payments. No doubt.

But we actually have the evidence that the FHO saved family medicine when it was introduced. It was stunningly effective, and if nursed back to health, will absolutely work again.

Sunday Snippets – November 3, 2024

Another in a weekly series of brief snippets of health care stories that bemused, intrigued and otherwise beguiled me over the past week along with my random thoughts on the matter.

Item: AI is now inventing things no one ever said. It turns out that AI can “hallucinate” (no really, that’s what they are calling it). Apparently the AI invents commentary that includes things like racial comments/violent rhetoric (!) and even medical mis- diagnoses.

My thoughts: My group is actually looking at AI to help with our Admin burden. While the technology shows promise – this is a useful reminder that we should all read what software generates before logging off. You will probably still save some time, just not as much as hoped.

Item: A new lung cancer vaccine that uses mRNA technology is entering trials. Somewhat ironically, this is what mRNA technology was being studied before the COVID pandemic, and its use for the COVID vaccines. The technology shows great promise to greatly reduce the side effects of cancer treatment, and provide more targeted therapy.

My thoughts: The “vaccine” term is probably going to need refining, because it’s not really preventing lung cancer (which is what most people associate with the term vaccine). Additionally, social media is still awash in mis-information about mRNA technology. So probably better to avoid that term. But at the end of the day I would agree what we are really in a remarkable time for cancer therapy with so many new treatments available. (Still better not to get cancer of course – so if you do smoke – quit!).

Item: Dr. Elaine Ma, a physician who went over and above the call of duty to organize mass vaccination clinics in the Kingston area at the height of the Covid Pandemic is asked to pay back the billings generated during those clinics. (Note I did not say income – Dr. Ma would have used a good portion of those billings to pay staff, supplies and other overheads).

My thoughts: I’ve been (frequently) told I’m too hard on bureaucrats in health care. That I come across as somewhat insulting and “un-presidential” when I complain about them. And every time I think to myself “I really need to take a deep breath and be hard on the problem, not the people” – along comes yet another example of rigid bureaucratic thinking and frankly bureaucratic stupidity that I wind up reverting to my old habits. I will say this, the residents of the Kingston area are a whole lot better off because of Dr. Ma , and the sooner the OHIP bureaucrats get this, the better. As for the OMA’s silence on the matter, it’s pretty disappointing.

Addendum: after writing this blog the OMA has confirmed that they have been helping behind the scenes. I’m glad to hear that they have been helping Dr. Ma, but I would state for the sake of their members that they need to be SEEN to be helping….

OMA Board Chair Dr. Cathy Faulds, who has been silent on Dr. Ma’s abhorrent treatment

Item: The Registered Nurses Association of Ontario blasted the government for not embracing nurses as a central to solving the primary care crisis.

My thoughts: I admire the RNAO for advocating for their members (no really, that’s kind of what a member organization is supposed to do). They’re wrong of course. Using Nurse Practitioners to replace physicians (as opposed to complementing them) will only massively drive up the cost of health care and worsen outcomes. But unlike certain organizations- see above – the RNAO stands up for its members.

Item: Walking pneumonia rates in the United States – and probably Canada – are spiking, particularly in young children.

My thoughts: It’s always awful to see children sick, and as clinicians we should be on the look out for this. BUT – thankfully the vast majority of cases appear to be mild, and if treated appropriately people are recovering. They may have a persistent cough for several weeks – but they are getting better.

Item: Collingwood’s newest physician says that the profession is endangered until the province ante’s up better pay. Disclosure – Dr. Ladda has joined my Family Health Organization and I feel we are lucky to have him.

My thoughts: Read my full blog tomorrow – written by a guest blogger so at least it will be coherent.

Item: A columnist in the Ottawa Citizen basically says that Premier Ford is outsourcing the family medicine problem.

My thoughts: A good friend of mine says it much, much better than I could. “We need the political leadership to step beyond name calling and giving token titles to people to win an election. If you want this province to thrive, rebuild and lead Canada again, it requires more than what we have seen for 20 years from ALL political parties .”

That’s it for this week’s Sunday Snippets. As mentioned above, watch out for a really superb guest blog tomorrow on how to fix family medicine.