Health – Page 4 – justanoldcountrydoctor

Open Letter to Premier Ford: Fix Family Medicine or Risk Losing the Next Election

Dear Premier Ford,

Just me again, your erstwhile, somewhat (but not completely) humble old country doctor. Like last time, I would point out that I am really not your harshest critic. I want to recognize that you have done much for health care infrastructure over the past few years.

For reasons that I cannot fully explain, the previous Liberal regime simply stopped building the necessary infrastructure to help Ontarians. Whether it was new (badly needed) nursing homes, new hospitals, or new teams, the Liberals basically did, well, nothing in terms of infrastructure. To your credit, you’ve reversed that trend and are building facilities we in Ontario need. (As an aside, you seem to like building things a lot!)

But all of that building will not mean much in two years (when the next election is – nudge, nudge, wink, wink) if, as projected, over 25% of Ontarians don’t have a family doctor. Yes, you can correctly point out that the decline in family medicine was caused by the Liberals (it truly was – Eric Hoskins was by far the worst Health Minister I personally have seen in my time in health care). You can point out that the Liberals slashed the capitation model favoured by most family docs that started the downward trend. You can also point out that their favoured Deputy Health Minister Bob Bell thought family medicine was so easy he could return to it after over thirty years away:

He even tried to mansplain one of the true leaders of family medicine on how the system should work.

Thx Doc Silvy. I suggest that we need fundamental re-think of highly prevalent, poorly managed conditions. Agree that GP focused practices have cropped up in many of these areas, Sports, MH, PC, Chronic Pain- real issue is lack of programmatic care across province. 1/4 https://t.co/hblPVJqDzX
— Bob Bell (@drbobbell) January 27, 2019

It’s true Bell and Hoskins were completely wrong. That will NOT matter because by 2026, the general public will say – “well you’ve had 8 years to fix this – you haven’t done enough”. That’s just how politics is, and I think deep down you know that.

You can, truthfully, also say that you are listening to organizations like the Ontario College of Family Physicians or the Ontario Medical Association (OMA) and who continue to go on about how team based care is the future of family medicine and how it can help solve the problem. You may not know this but I was the founding Chair of the Georgian Bay Family Health Team . I happen to believe in physician led team based care.

But here’s the thing. It will take a minimum of five years (if we’re lucky) to build out all those teams. That’s assuming the bureaucrats from the Ministry GET OUT OF THE WAY and let front line family physicians be in charge of the teams. But we are losing family doctors by the week. The people of Ontario can’t wait five years.

There is one thing that can be done now however, to stem the tide, and stabilize the system. You need to give comprehensive care family physicians an immediate, and significant raise. How significant? You will need to give an immediate 35% increase to comprehensive care family docs along with annual normative increases for the next four years. If you think that’s outrageous – I invite you to look at Manitoba’s contract or Saskatchewan’s or British Columbia’s. The competition for comprehensive care family doctors has increased significantly, and Ontario is falling behind.

I can pretty well guess what your “advisors” are telling you. They will say you are in arbitration with the OMA, just promise to abide by the result. Honestly, I do believe you will abide by the result, both this year and next.

But…

Arbitration will take months this year, and months if not a year next year. Frankly, I doubt that the OMA, despite their strong words, will advocate for an increase of the amount necessary for comprehensive family medicine (hopefully I’m wrong).

I have absolutely no doubt that the Arbitrator, William Kaplan, will give a raise to family docs, especially after the recent award to nurses. But if the raise isn’t enough, you going out to the general public in two years and saying “we honoured the arbitrators rulings” – will make zero difference to the close to five million people who won’t have a family doctor. They will still blame you for not having been pro active.

William Kaplan, Chair of the Arbitration Board

Listen, I’m on the conservative side of the political spectrum. I’ve always voted for the Conservatives in every provincial election since I was eligible to vote. I live in Simcoe – Grey which is one of, if not the most strongly conservative ridings in Ontario. Heck, in the early 1990s we were the ONLY riding east of Manitoba to vote for a Reform Party MP.

I’m telling you that most of the voices on the ground are really upset about the lack of family doctors. We have about 7,000 patients without a family doctor in our area last I heard. It’s true that when asked who they will vote for in polls, they, like most recent polls, say they’ll vote conservative. However, they always add “I guess, there’s nobody else out there”. That softness in your vote is a problem, and that softness doesn’t show up in the poll numbers.

Listen, I want you to win the next election. I personally think the NDP would be a complete disaster. I have no faith the Liberals, who showed just how much they hate doctors, have changed their tune. But in order to do that, you’re going to need to bite the bullet, and stem the haemorrhage of family docs.

Go to tell your negotiations team to offer up a deal that strengthens family medicine. Mask the increase with things like retention bonuses (like Manitoba) and matching RRSP payments (like BC) and other methods (paid admin time, paid supervision of team members and pensions would be nice). But get it done ASAP.

Otherwise, I genuinely think you will be in more trouble than you might be led to believe by your handlers in 2026.

Your sincerely,

An old country doctor.

About Asking for Reduced Admin Burden From the MOH….

Lots of talk on the net about how the economic model for family physicians no longer works in 2024. My own blog site has had guest posts dedicated to this issue. There has been some criticism of this position. Dr. Darren Larsen in a reply to the post linked above suggests he is “not seeing or hearing…ideas for solutions“. He further states that all paying doctors more will do is create a “better-paid, unhappy professional. Nothing has changed.”

Others have made the similar comments. There is nothing philosophically wrong with the argument to reduce workload instead of raising pay. Practically speaking however, history has repeatedly taught us that the Ministry of Health (MOH) bureaucracy is incapable of delivering on that promise.

Some personal stories:

In the mid 2010s I was a Peer Lead for OntarioMD (no really!). I was frustrated by the Ontario Lab Information System (OLIS) because I had to manually retrieve all the lab work for a patient individually in their chart. Hospital Report Manager (HRM) by comparison, sends reports on all my patients directly to one inbox. (why we need two systems – and now more, is another story). The then VP of OntarioMD informed me they were working on “Practitioner Query” – which would allow me to get all my lab work from OLIS in one inbox. This was supposed to be ready in six months. That was over a decade ago.

From 2014-2018, thanks to the vision of my colleague Dr. James Lane, we developed an integrated health portal as part of our Health Links project for South Georgian Bay. For $35K a year, we were able to ensure that nursing homes could message physicians on their EMR. We dramatically reduced paperwork for physicians from nursing homes, improved health care outcomes, and reduced hospitalizations thus saving the entire health system money.

The MOH bureaucracy couldn’t wrap its head around this and wouldn’t allow it to continue.

For those of you who think I should have told people about this project, I wrote an article in the Toronto Sun about it. Afterwards, I got invited to do a presentation on this with the then CEO of eHealth Ontario and her senior team. Heck, when I was a keynote speaker at OntarioMDs Every Step conference in 2019 (no really!) I presented this project. The then head of the MOH Digital Health Team was there and heard it. Still, the bureaucracy couldn’t see their way towards allowing a project that saved physician time (and improved health care outcomes) could continue.

Ok, ok, so this blog is just for me to complain about not being listened to right? Well no, there are multiple other examples.

One workload issue for family physicians is keeping track of which of our patients get immunized for which vaccines. If only there was a central tracking system that sent the information to us directly. Wait, there is! The Covax system for tracking Covid vaccinations. Obviously the easiest and most sensible thing to do is expand the already existing system to add all the other vaccines so we get notified (eg when public health gives Gardasil). Yet 3 years after Covax, the MOH can’t even make this simple common sense change.

More? When I was on the SGFP Executive, one of our senior physicians told us the story of how he was on a working group to make the schedule of benefits (the fee schedule for Ontarios doctors) easier. After six months of meetings, they made a decision to add a comma to the descriptive sentence of one code. One comma in an 800 page schedule.

I could go on but you get the point. It’s fine for the MOH to say that that they promise to reduce the Admin burden for family docs. But frankly to these aged and cynical ears, it just sounds like them saying “This time we really mean it, honest!” – kinda like when Lucy promised to hold the football down for Charlie Brown for real this time, with predictable results.

Look, we have a five alarm crisis in family medicine in Ontario. Just about every week brings a story of another physician who is struggling with the economics of running a practice, and is considering quitting.

As with all emergencies, we need to have an effective triage system in place. Deal with the most urgent thing first, then go on to other things. We clearly can’t wait until 2034 for the MOH to implement some of the workload reducing schemes they might have (and no matter how much they promise they really mean it – it will take that long). So the first thing that needs to be done is bring financial stability to family practices so that they can continue to function while we sort out everything else.

Now, given Ontario physicians are in the midst of negotiating a new contract with the Ontario government, I expect the MOH team to say to our own negotiations team something like – “I know you guys want X% increase, but we can only give you 1/2 of that, but we promise to reduce your admin burden so you are working less hard”. I would do the same if I was them.

But, my expectation, and the expectation I think of the majority of doctors in Ontario, would be that the OMA negotiations team looks at the MOH team, and quotes the best engineer in the history of Starfleet to them.

With apologies to Geordi Laforge, B’elana Torres, Trip Tucker, Jett Reno, Andy Billups, and Hemmer – but Scotty was the BEST ENGINEER in the history of Star Trek!

The first step towards fixing the crisis in family medicine is a new physicians service agreement that stabilizes family practices. Once that’s done, work can begin anew on health systems transformation/workload reduction and so on. To try to do it the other way round, or even hand in hand, is a recipe for further collapse of the health care system.

Mark Dermer: On the Ethics of Telling Residents to Avoid Comprehensive Family Medicine

Recently Maria DiDanieli, a system navigator with the Burlington Family Health Team who holds a Masters in Medical Bioethics, wrote an article criticizing myself, Dr. Silvy Mathew and Dr. Nadia Alam for recommending family medicine residents NOT start a comprehensive care family practices at this time. Dr. Mark Dermer responded so eloquently to that, that I asked his permission to reproduce his response as a guest blogger, and he kindly agreed.

Dr. Mark Dermer, a recently retired family physician whom I’m honoured to have as a guest blogger today.

As a recently retired family physician, I am troubled by the fact that you (Maria DiDanieli) have mistaken the fact that you work adjacent to family doctors as sufficient to understand what they face. Worse, your assessment of Drs. Alam, Gandhi and Mathew is unjust.

But that’s not why I am commenting. Instead, I am coming at this as someone with some experience in medical ethics, both as a long-time member of community and teaching hospital ethics committees, and as a teacher of medical ethics to family medicine residents.

To put it simply: Your ethical analysis of my colleagues publishing the opinion piece in question is both facile and flawed.

I crafted an ABCDEF mnemonic to help residents remember six fundamental principles of medical ethics:

A – the right to Autonomy in decision-making

B – the moral duty of physicians to be adhere to Beneficence when caring for patients

C – the obligation to safeguard patient Confidentiality

D – the patient’s right to receive Disclosure of all information pertaining

E – Equity in dividing finite resources among patient populations

F – First, do no harm (nonmaleficence)

We then apply these principles to a given situation, understanding that the principles might conflict with one another. It is very rare that a single principle can be used to judge a given question. We also must accept that there are almost never absolute rights and wrongs, just better and worse answers.

I am confident that we can agree that the current primary care crisis is first and foremost a violation of equity: present circumstances have divided the people who want a family doctor into those who have one and those who don’t. I also expect that you are aware of the evidence that demonstrates that patient outcomes are better when people have an ongoing relationship with a family doctor.

But you make the elementary mistake of applying a single ethical principle, nonmaleficence, to the matter at hand. Furthermore, you seem unaware that physicians graduating from family medicine programs have been entirely consumed with their training over the previous 5-6 years, nor aware that the medical education system has largely withheld what graduating residents will face as they enter practice. In that light, the letter is a long overdue disclosure that brings transparency to the current state of family medicine.

That’s right, physicians have the right to disclosure too. We also have rights as people to autonomy, confidentiality and equity. Yet when it comes to our work, we are forced to accept legislated pay and work conditions from a monopoly payer, the government. And the government uses the fact that physicians are independent contractors to justify the fact that we are not entitled to the same cost-of-living increases paid to other health or educational professionals.

Finally, I think you fail to recognize that in family medicine, we face unusual challenges to persistently align with all the principles of medical ethics, which work best when applied to “cases” (a single patient at a single moment in time). In contrast, family physicians’ work is longitudinal and includes significant responsibility to populations of patients as well as to individuals. That means that we accept short-term harm when we do things like stick vaccination needles in people’s arms or wean them from opioids, understanding that we are looking to provide a net benefit in the medium to long term.

To my mind, that is precisely what Drs. Alam, Gandhi and Mathew have done. In other words, they are acting very ethically. For while the short-term consequences of their disclosure may accelerate the intensification of the immediate crisis, the sooner the crisis provokes action the sooner we start climbing out of this horrendous hole.

Open Letter to All Family Practice Residents

The following letter was jointly written by the three of us and published in the Toronto Star on February 20, 2024. It is being reproduced below so that we can share the letter on Facebook as we believe it will be of interest to physicians across Canada.

To All Family Medicine Residents,

We are writing to say congratulations! You are nearly at the end of a decade of hard work, perseverance and sacrifice; ready to start your career and “real life”. You have joined a beautiful and unique specialty. You will be the key to the healthcare system. You will find answers when patients arrive with ambiguous symptoms. Others will tag in and out of a patient’s health journey. You will stay and be an essential part of the beginning, middle and end of every patient’s story. You will save lives.

Your skill and knowledge are unparalleled, and there is no substitute for your expertise.

Which is why with heavy hearts, we, the undersigned, recommend that you do not start your own family medicine practice in Ontario. Not right now.

Family medicine is in crisis. Family doctors in Ontario are unable to provide the care they could and should. We face unprecedented levels of administrative burden, unsustainable business expenses, lack of healthcare resources, lack of social and cultural support for our patients and ourselves and finally, a lack of respect. This has led to widespread burnout and exhaustion.

In short, it is becoming frankly unsafe to run a family practice in Ontario, especially for those just starting.

We are family doctors with decades of experience. We are also physician leaders, past-presidents and board directors of the Ontario Medical Association (OMA), academic faculty, and health policy experts. We understand the situation well.

Do not sign that contract. Do not sign a lease, hire staff, buy equipment, contract with an EMR or any of the million things that must be done so that you can start a comprehensive care family practice.

Starting a practice at this time will require you to continue to sacrifice everything else in your life. If you have debt, you may not be able to pay it down, let alone start living the life you and many others have postponed for so long. You will struggle to spend time with your family, buy a home, care for vulnerable loved ones and more. You will continue to work at a non-stop pace, this time with no end in sight.

You will burn out and like many others, leave family medicine for good. This is why millions of Ontarians no longer have a family doctor.

The Ontario Ministry of Health can solve this crisis.

Governments in Manitoba, Saskatchewan and British Columbia have done so. This past year, they made family medicine a priority – and backed their words with targeted funding toward key programs to support both new and established doctors. It comes as no surprise that they have welcomed hundreds of new family doctors into their communities.

If they can do it, so can Ontario.

What can you do in the meantime? Work in hospitals, hospices, operating rooms and long-term care. Work in obstetrics, anesthesia, as a hospitalist, in emergency or palliative care, oncology, sports medicine etc. Be a locum. Bide your time.

You are skilled, smart, and adaptable. Your knowledge is extensive, demonstrating an unmatched depth and breadth of training. Use it.

When people leave comprehensive care family medicine, they almost never come back.

We don’t want that to happen to you. When the government of Ontario recognizes family doctors as the foundation of medical care, negotiates a fair contract and improves health policies to reflect patient needs in 2024… well, when that happens, we will write a different letter and welcome you to the world you were meant to be in.

We hope by then it is not too late.

Sincerely,

Dr. Nadia Alam, comprehensive care family physician and anesthetist, past-president of the OMA

Dr. Sohail Gandhi, comprehensive care family physician and hospitalist, past-president of the OMA

Dr. Silvy Mathew, comprehensive care family physician and long-term care, past-board director of the OMA

Dr. Soni Reflects on the Delays in Emergency Rooms

Dr. Deepa Soni, and Emergency Room physician for over twenty years, reflects on the case of a young woman with appendicitis, and the delays in getting her care.

NB: Recently, Julia Malott spoke out on X (formerly known as Twitter) about how terrified she was about Canada’s health care crisis. She wrote how her daughter had not eaten in 18 hours as she continued to wait for surgery for appendicitis. She expressed concern about the lack of the beds and wondered if her daughter would get surgery before the appendix ruptured.

My friend Dr. Soni, who has worked in an Emergency Department for over 20 years, had, as usual, a very thoughtful and well spoken X thread of her own. (Dr. Soni was NOT involved in the care of this young woman). I thank her for allowing me to reproduce her thoughts here.

The only way these stories (about long delays in Emergency rooms) will stop being the norm, is when patients start sharing their experience like this mother did. Only voters can make federal and provincial governments change because votes are the only currency that matter. Doctors and nurses have been raising alarm bells for years without success.

Canada has one of the lowest number of hospital beds of all the OECD countries, around 2.3/1000 people. In comparison countries like Japan, Korea and Germany are around 13/1000.

Graph showing how Canada fourth from the bottom (!) in hospital beds per capita.

Why does this matter? Having low hospital bed numbers means that words like “flu surge“, and “winter surge” — which have been used for decades to explain away long wait times and hallway medicine, are actually not “surges.” Rather, they are the expected backlog in a system that lacks adequate beds and resources.

The population of Canada is increasing and aging. We are about to enter a silver tsunami where a large cohort of our population will be over the age of 65 and many over the age of 85. This will place unprecedented pressures on our health care system.

What happens when the hospital bed capacity is outstripped by the numbers of patients needing care? It means that the elderly patient who needs admission to a hospital bed to recover from a heart attack has no bed to go to and spends days “admitted” in the emergency department. Bureaucrats call these “unconventional spaces.” What they really are, are stretchers.

Photo of admitted patients lying in stretchers in a hallway as no beds available (found on X)

When the vast majority of the emergency department beds are being used to take care of hospital patients, that means that patients that are waiting in the emergency department waiting room, will wait for hours for care, much like this story is describing.

Media needs to scratch beyond the surface and hold government to account. Real solutions are going to require thinking beyond the four-year election cycle. What will our system look like in 20 years? How do you plan for that?

It’s going to require recognizing the backbone of our healthcare system is primary care. Family doctors are overwhelmed by administrative burden, trying to run their offices and taking care of large practises in the community without adequate resources.

Build community infrastructure with resources like palliative care so that people can remain in their homes comfortably in their last days; and sufficient homecare services so that patients can receive antibiotics and other intravenous treatments at home to ease the pressure on hospitals. These services are vastly underfunded and do not have enough staff to properly provide care for everyone that needs it in the community.

It’s going to require building more nursing homes, retirement homes, seniors services and dementia care programs, as our elderly population will be the largest it’s ever been in this country.

Incentivize and properly pay hospital nurses so that we can recruit and retain them to be able to run departments and programs properly. Currently, agency nurses make at least two times as much as a hospital nurse, and this has created instability in the workforce. Governments need to show that they value nurses and the important work that they do.

Creative solutions like interprovincial licensing of doctors and nurses and a National Pharmacare program will help. While the idea of recruiting from other countries sounds like an easy quick fix, it will not solve anything if those newly obtained doctors and nurses find themselves overworked and burning out soon after arriving to Canada. The system problems are going to impact them just as they have impacted those who are already working in the system. This type of strain is what contributes to moral distress and burn out.

The backlog in the emergency department is a reflection of multiple failing areas that create an overall system that is strained beyond capacity. With each passing year, Canada’s healthcare system has become more and more stretched, trying to provide more care to more people, with fewer resources. Throwing Band-Aids at it is like trying to mop up the floor under an overflowing sink instead of trying to figure out how to turn off the tap.

Stories like this one are happening every day in Ontario and all of Canada. Most patients and families are too busy dealing with the acute health problem to take the time to write to their MP/MPP or to go to the media. But when people take the time to bring these stories to light, a critical tipping point will eventually occur where they can no longer be ignored by government. Because votes matter.

No one who went into healthcare wants to work in a system that makes patients feel like this story illuminated. But we need more voices bringing their stories out in the open. It will improve the system for the people working in it, and for the people receiving care within it. And that is better for everyone.

What Would I Do if I Got Sick? I Would go to Turkiye.

NB. I am a consultant for Medicte, a medical tourism firm that connects people with the Acibadem Health Group in Turkiye. I appreciate my two loyal fans may read this to be an “advertorial” – but it does represent how I feel.

Yours truly at an Acibadem Hospital in Turkiye with their team and representatives from Medicte

Recently, Leger released the findings of a survey that polled Canadians on their thoughts about the health care system. 70% of Canadians worried about not being able to get high quality health care. Surprisingly, only 37% thought the health care system was poor – did 63% not need medical care recently? But the number that should demoralize all of us is that only 17% feel the system will improve.

Like everyone else of a certain age, I’m coming to the realization that the one fight I won’t win, is the battle against time. More of my friends and colleagues are developing health issues. While I’m blessed to be in good health, like 83% of Canadians, I realize that the current health care system (which doctors call horrific and inhumane ), will not provide the access and care we should expect as standard in this country. I can only see things getting worse in the near future.

It does not help that I live in the health system every day. I’ve watched patients I really care about suffer in ways that I would not have imagined possible. Young people with cancer not getting treatment for three months. People with joint pain waiting a year for surgery. Patients developing complication after complication while on wait lists to access necessary treatments.

Most heartbreakingly, I see the toll that the burnout of working in such a hellishly damnable health care system is taking on doctors, nurses and other allied health care professionals on a daily basis.

That’s why I recently made the decision that if I, or someone in my family needed health care, I would seek care outside of Canada. I am not alone in this. The data is hard to get at, but going back as far as 2014, between 52,000 to 217,000 Canadians were seeking health care outside of Canada annually.

There are a variety of reasons to seek care outside of Canada, and specifically Türkiye:

Getting immediate care. I could get hip surgery next week, not next year. Cancer patients get all the tests they need done within a week, not three months like I’ve seen.
Getting treatments that are not available in Canada. Canada offers a host of great medical treatments, but many are not covered by government plans. Lap Band surgery is one. New, emerging radiation therapies for pancreatic cancer is another. There are more. All of these are available in Türkiye.
Getting better allied health care support. Canada has GREAT nurses and other allied health care workers. But the system does not let them care for patients the best. Last time I was on call at my hospital, I overheard the nurses talking about how they each had 7 patients to look after for the shift. The safe number for an acute care hospital ward is 5 patients per nurse. We have excellent nurses but if you are constantly working at 40% over capacity, things are not going to go well. At the Acibadem hospitals in Türkiye, they have 4 nurses for 15 patients (3.75 patients per nurse).
More cost effective care. I’m fortunate I can afford to pay out of pocket for care if needed. Worst comes to worst I’ll put off retirement for a couple of years to pay for things if necessary. But even I would have trouble with $200,000 (U.S.!) that B. C. resident Allison Ducluzeau spent on her cancer care. Costs in Türkiye for most procedures I looked at are generally less than half of what it costs in the U.S.
First World Standards for Health Care Treatments. All of the Acibadem hospitals are JCI Accredited (the global leader in health care accreditation agencies). This puts them on par (and in some cases better) than top European hospitals.
Türkiye is a well sought after Medical Tourism destination. Medical Travel Market recently highlighted 12 reasons why Türkiye was so well sought after including cost, world class facilities and cutting edge treatments. 1.2 million people went to Türkiye for medical tourism in 2022, mostly from Europe.

As part of my consulting work, I went on a fact finding tour to Türkiye and visited the Acibadem hospitals. To say my jaw dropped would be an understatement.

The team and I reviewing the process for orthopaedic care with their top spine surgeon.

The hospitals (there are 21 in the Acibadem group) look like hotels. Each room is private. The wards are immaculate. All of the staff were incredibly attentive (and yes, spoke English).

I asked to see the MRI, and the staff wanted to know which one (!). Their approximately 170 bed hospital had THREE MRIs, specialized for different conditions. This is on top of the CT scans, gamma knives (cancer treatment), PET scans etc etc. All of the equipment was brand new. I especially liked the MRI that projected a movie onto the equipment, to help children stay calm during the procedure.

This MRI projects a movie onto the surface to help children (and some adults) stay calm during a claustrophobic procedure

I also ran into a couple of top ranked Turkish footballers (soccer players) while there. The Turks are as crazy about football as we are about hockey. Their top athletes go to the Acibadem group.

But what’s more impressive than the top ranked doctors, nurses and equipment is their philosophy of how to provide health care. If you were to sadly, get cancer, you would see all the specialists you need to see (surgeon, medical oncologist, radiation oncologists etc) on the same day. Any tests you need would be organized sequentially and rapidly over the next couple of days (if not the same day). You would have a full treatment plan within a few days.

Contrast this with Canada where you have to have an appointment with one doctor, then wait x number of weeks to see another then x to see another like my patients currently do. All while the cancer continues to grow.

Also, for the record, I did wind up getting care myself at Acibadem. Bad teeth run in my family, and so I went for a dental check up. The dentist examined me, put in two fillings, got the oral surgeon to come by and took out two teeth that were beyond hope, all during the same visit. This would have taken multiple visits in Canada. You could say I put my money where my mouth is. And yes, the care was excellent.

I appreciate this sounds like an advertorial. But the reality is that more and more Canadians are getting frustrated with the long waits for health care and seeking care outside of Canada. It may have started off with people seeking lower cost cosmetic surgery, but now things like orthopaedic surgery, cancer treatments, organ transplants, dental implants and even cutting edge infertility treatments can be had for those willing to travel.

There is never a guarantee of a successful result with medical treatments anywhere (including Canada). If considering leaving the country for care, people should do their due diligence. Make sure you deal with a reputable firm and first rate hospital.

I’ve made my decision, and I know where I’ll go.

If you or anyone else would like to explore options for out of country health care, contact Medicte for a free consultation.

DFCM at Temerty Faculty of Medicine’s Stunt is DANGEROUS for Physicians AND Patients

I’ve been involved in medical politics for some time and in health care for much longer. I’ve seen a lot of foolish things. And yet, I confess, I’m still dumbfounded when some really smart people come up with a really stupid ideas. I guess I’m just a slow learner.

The most recent of these ideas comes from the Department of Family and Community Medicine (DFCM) at Temerty Faculty of Medicine. (Temerty is the name for the University of Toronto Medical School – and no, I have no idea when or why they changed their name to Temerty). In an attempt to address the crisis in Family Medicine, Drs. Pinto/Kiran and Martin would like the governments to declare a state of emergency in access to primary care.

Do I understand wanting to draw more attention to the crisis in Family Medicine? Of course I do. Family Doctors are planning to leave the field in droves. Compensation for family medicine has failed to keep up with inflation much less given them a raise. The admin burden makes one feel like Sisyphus (In Greek mythology Sisyphus was dammed by the gods to roll a boulder to the top of a hill only to have it roll suddenly back down to the bottom when it got close to the top and thus be forced to roll it up again. A more apt description of the family medicine paperwork burden I have never seen).

Heck across the country our whole health care system is in crisis, not just family medicine. Patients are not getting timely specialist care (some even choosing euthanasia as a result) as well as family practice care, resulting in worsening health care outcomes for all Canadians. We should be screaming about this.

But I honestly don’t think Drs. Pinto/Kiran/Martin (who combined have more letters after their name than the entire alphabet) could possibly have thought this recommendation through. Frankly, I’m genuinely left wondering if they even know what the government declaring “a state of emergency” means. The only way to enact this, is to invoke the Canada Emergency Act.

This Act clearly lays out what governments can do to solve a crisis in any particular area. And it’s not pretty. It includes:

giving the government the “ability to make orders or regulations that are believed, on reasonable grounds, to be necessary…”
Directing specified persons to render essential services…
Regulating the use of specified property, including goods…
The imposition of fines or imprisonment for contravening on any of the measures declared..

In short, having the government declare a state of emergency gives them a whole lotta power to do a whole lotta things. I guarantee you not all of those things will be smart.

No one in their right minds is going to argue with the issues identified in the letter three doctors wrote about:

The crisis in family medicine is real. There has been a lack of investment in primary care. This will get worse. This will cost the health system more money in the future if we fail to fix the problem. And yes, thank goodness somebody other than a cranky cynical old country doctor wants a significant overhaul and feels that “modest changes are not enough”.

But – to tell the government to enact a state of emergency, giving the same bureaucrats who have completely screwed up the health care system for the past thirty years almost unfettered power is not the solution. Let’s look at some of the goals of these three doctors:

If there is a state of emergency – do you know how these pointed headed bureaucrats will take “decisive action” to “ensure every person in their jurisdiction has equitable access”? You think they will licence more physicians? You think they will allow Ontario Health Teams (OHTs) to have strong physician leadership (which is the ONLY thing that has been proven to work in accountable care type organizations like these OHTs)?

I got news for you. The pointy headed bureaucrats will simply mandate zones, unilaterally determine how many patients a doctor must roster, and will make decisions in the interests of “urgency” given the new powers they just got from a state of emergency to show they are doing something.

Say for example the recent situation when Royal Victoria Hospital had to close down their obstetrics service. Hell that Gandhi fellow delivered babies 20 years ago, he probably hasn’t forgotten what to do – send him there to cover so it doesn’t close, he’s only 45 minutes away. Or a hospital about close their ER again – force a local doc who hasn’t worked in ER for 15 years to do so. 7,000 patients without a doctor in a certain town? Have each family doctor take a couple hundred more – even though those docs are already working night and day. (Trust me – these ideas will not sound outlandish to bureaucrats.)

Drs. Pinto/Kiran/Martin know that to make inroads into solving the primary care crisis you need to do three things:

increase the payment to family physicians to reflect the work they do. Decades of sub inflationary wage increases (cuts by another name) have made it untenable to run a family physicians office. Pay family docs more and don’t be afraid to say so.
The OHTs actually have potential for improving health care, but they need strong family physician leadership – not any other health care professional (and certainly not bureaucrats) – family physicians need to lead this. (The OMA has plenty of evidence on this and has shared with the government and will share with you).
- Interchangeable IT technology that allows easy access to patient data and thus minimizes the admin burden.

The only reason I can think of for doing this is some sort of political stunt to embarrass the politicians. Heck I agree politicians should be embarrassed for how badly they’ve messed things up. But to do it in a way that gives them more power (not less) instead of demanding a true collaboration with family physicians doesn’t strike me as a very smart move at all.

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

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

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

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

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

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

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

From Dr. Zubek’s Facebook page:

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

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

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

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

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

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

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

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

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

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

My two cents:

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

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

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

We Should Return to the Health Care Model Tommy Douglas Envisoned

In 2004, the CBC surveyed Canadians to see who would take the title of “The Greatest Canadian.” The winner was former Saskatchewan Premier Tommy Douglas. Douglas is widely, and correctly viewed as the founder of socialized health care in Canada.

His selection speaks not only to the dramatic impact he has had on this country, but just how much Canadians value health care. I will dispense with calling it “free health care” because that just isn’t true. Our tax dollars pay for it. But those dollars are supposed to provide care for all those who need it.

Tommy Douglas, the Greatest Canadian, and the founder Medicare.

As our health care system continues to collapse all around us, it’s worthwhile, I think, to look back at the type of health care that Douglas envisioned. The truth of the matter is, that it is quite a bit different than what we have today. And I think, is not at all what Douglas would want.

According to “The Canadian Encyclopedia“, Douglas’ views on health care were shaped by a number of events in his early life.

As a six year old, Douglas fell and cut his knee. Unfortunately, he developed osteomyelitis ( a bone infection) and the consequences hampered him for his entire life. He had numerous operations and at one point doctors in Winnipeg considered amputating his leg. Fortunately, a well know orthopaedic surgeon (Dr. R. J. Smith) offered to operate for free, so long as Douglas allowed medical students to watch. This saved Douglas’ leg, and helped convince him that health care should be readily accessible to everyone.

Later, as a young man, he moved to Weyburn Saskatchewan, and was dismayed by the complete lack of medical care. He buried a 14 year old girl who died of a ruptured appendix because she couldn’t get medical care. He also vividly told of burying two young family men in their 30s, who simply couldn’t afford to get medical care.

These experiences helped to shape his belief that we could do better as a country. I would suggest that all Canadian should share the belief that one should not have to choose between going bankrupt (or dying) and getting basic medical care.

As premier of Saskatchewan, he implemented the Saskatchewan Hospital Services Plan covering the needs of patients admitted to hospital. In 1961, he implemented the Saskatchewan Medical Care Insurance Act, that provided medical insurance for all residents of Saskatchewan. This of course eventually led to other provinces and the Federal Government adopting similar programs.

The wording is important, and I think speaks to what Douglas was trying to achieve, and frankly, where I believe we need to go back to. The plan was “Insurance”. With all the benefits, AND RESPONSIBILITIES that go along with insurance.

Here’s the thing. In Canada, ever since the Canada Health Act, we have really deviated far from what Douglas really envisioned. He never ever wanted a system where you could go to any health care provider and get assessed without any responsibility on your part. Indeed, he spoke to that quite eloquently in the Saskatchewan Legislature on October 13, 1961:

“I want to say that I think there is a value in having every family and every individual make some individual contribution. I think it has psychological value. I think it keeps the public aware of the cost and gives the people a sense of personal responsibility. I would say to the members of this House that even if we could finance the plan without a per capita tax, I personally would strongly advise against it. I would like to see the per capita tax so low that it is merely a nominal tax, but I think there is a psychological value in people paying something for their cards. It is something which they have bought; it entitles them to certain services. We should have the constant realization that if those services are abused and costs get out of hand, then of course the cost of the medical care is bound to go up.”

Douglas intuitively grasped that if people perceive something as “free” they will start to lose their sense of using it responsibly. That’s why the initial Medical Insurance Act was just that. A form of insurance funded by the taxpayer, and like all forms of insurance, there was a deductible and reasonable limitations.

People were able to now access health care, for a small fee that allowed them to recognize that they too had to take some responsibility for how they used the system. They also had to realize that not everything was covered. Basic health care yes. Options like wanting, say, a private room instead of a ward bed in hospital – well that would be an extra.

There are many problems with the Canada Health Act. But the most fundamental is that it is based on the premise that you can endlessly get something (in this case health care) for nothing. Gutless politicians (from all parties) continue to promote this mantra in never ending attempts to woo votes as opposed to, you know, actually telling the people the truth. Namely, that people should take some responsibility for how they use the health care system.

By continuing to perpetuate the the lack of accountability, our cowardly politicians have created a culture of entitlement instead of a culture of empowerment. Many (not all) people believe that they should be able to get all manner of testing because it’s “free”. I’ve been blessed to have a very pragmatic practice in general, but even I have had to tell people that I will not be ordering the serum rhubarb levels their naturopath wanted because it would be “free” if I ordered it instead of them, or the full body MRI that some “wellness consultant” asked for.

It’s time to bring some patient accountability back to health care. And the first step in that would be to go back to the model that Tommy Douglas had proposed all along.

Dear OMA Board Member, About That Mandate for Negotiations

Dear OMA Board Member,

I read, with interest Ontario Medical Association (OMA) Board Chair Dr. Cathy Faulds update last Friday. There’s the usual information in there about the goings on at the OMA (which sadly not enough members pay attention to, though they should). Critically for most members however, was this comment by Dr. Faulds:

“The board will hold a special meeting at the end of September to finalize the negotiations mandate for use by the Negotiations Task Force (NTF)..”

This is a big step in the negotiations process and to truly understand that, members need to understand what a “mandate” is. Allow me to briefly expand on what Dr. Faulds wrote. The short version is that a mandate is the minimum offer the NTF can accept from the government. If the government offers an increase that is equal to or exceeds the mandate, then the NTF will automatically accept that offer on behalf of the Board.

The corollary to that, which some Board members did not understand when I was on the Board, is that if the mandate is met, and the NTF accepts – then it will automatically mean that you as a Board have to accept the offer as well. As per Board rules, you will then have to endorse the government offer to the membership. You can’t very well tell the NTF “you must achieve XYZ”, and if they do achieve XYZ, turn around and say it’s not enough.

Therefore, it is incumbent on you as a Board, to make sure the mandate is sufficient for the membership as a whole, given the times we live in, and the environment around us.

To that end, without spilling specific secrets, I will state that there was quite a lot of discussion about what an acceptable mandate was during my time on the Board. There were some Board Members who wanted to be “reasonable” and some who wanted to take a hard line and keep the mandate high.

I would, respectfully, point out that for the most part, mandates are never met. Usually the NTF comes back to the Board with “we tried – but this is the best we could get” and presents that to the Board. To be clear, I’m referring to all labour negotiations in general, not just physician ones. Negotiations Legal Counsel told us this last time, just ask them. Whatever you (or any Board) sets as the initial mandate, there is a strong chance the NTF will come back to you later and ask you to lower that mandate.

You will need to keep that in mind when setting your mandate.

To that end, I would encourage you to recognize that the time really has never been better to set the bar extremely high for the NTF mandate. It’s not just that physicians are considering leaving the profession. It’s not just that health care is collapsing all around us. It’s not just the ongoing problems with not just recruiting, but retaining physicians. You already know about all of those issues in excruciating detail.

No, the reality is that we now also have some significant competition for physicians within Canada from other provinces. And I mean strongly significant.

Not sure how many of you have seen this summary form the recently approved Physicians Services Agreement (PSA) in Nova Scotia. On the surface there would appear to be a fairly minimal 10% raise over four years. A deep dive however shows significant add ons like improved parental benefits, funding for overhead, funding to hire allied health care professionals, funding for admin work, enhanced FTE and income stabilization for specialists and so on. That plus a retirement fund!

Similarly, in Manitoba, their recent agreement was widely hailed as a landmark and a game changer. I spoke to a friend of mine from Manitoba who confirmed that it too contains things like a retention bonus ($21,000 and higher for those in rural communities), funding for admin time, funding for new models of care, additional funding for those patients who are older and an equity lens applied to fees. In short, the increase is widely viewed to be in the double digits percentage wise per year.

Look, I know the NTF knows all the stuff I’m pointing out (but others who read my open letter may not). I also would acknowledge that Dr. Mizdrak is a fine chair for the NTF and is (in a very good way and said with total admiration on my part) a real pitbull on behalf of the profession. I also have full confidence that the NTF did it’s due diligence in reviewing the many asks by the leaders of all the specialties.

But at the end of the day, it is up to you, dear Board Member to set the minimum acceptable deal (mandate) and it is up to you dear Board Member to ensure that Ontario remains a competitive place to attract physicians.

To that end, you must ensure that if there is a negotiated agreement, it must at least equal the increase in Manitoba or Nova Scotia (whichever is higher). Anything less would, quite frankly, be rightly viewed as the Board selling the profession out. (If we wind up going to arbitration, that’s a different story – but at least we will have gone there because the Board refused to take a sub optimal deal).

All of which is a long way of saying that since it is quite likely that an initial mandate may not be met, it is incumbent on the Board to set a mandate for the NTF that is HIGHER than what was achieved in Manitoba/Nova Scotia. This will allow for the usual process of the NTF having to come back and say what parts can be achieved and what can’t, and allow some wiggle room.

If you set the bar lower, well, frankly, I have to wonder how you can justify saying that you are advocating for the Doctors of Ontario.

Yours truly,

An Old Country Doctor.