Why I’m Going to Vote “Yes” to the PPSA

Recently, the Ontario Medical Association (OMA) announced a Proposed Physicians Services Agreement (PPSA) with the MOH. The agreement is a year overdue, one of many delays caused by the Coronavirus Pandemic. It outlines a 3 year framework (retroactive to April 1, 2021) for funding patient services that are provided by physicians.

Like every single agreement between physicians and government in my almost 30 year career, it is basically something out of a Clint Eastwood movie.

The Good:

Increasing the number of family physicians who can be in a captitated model (salary + performance benefits). Increasing/improving the number of Alternate Funding Plans for specialists. Increasing/improving the number of Hospital On Call plans. Continue support for Malpractice Insurance. No Hard Cap. Improved parental benefits. A few others.

The Bad:

Some “aspirational” targets that seek to control physicians offices (particularly family physicians). I have absolutely no doubt that these “aspirational” goals will be mandatory goals in the governments opening position for the next round of negotiations. Just look at the governments position for Arbitration the last time around. The current aspirational goals will seem eerily familiar to those who have been following negotiations in detail.

Additionally, there seem to be a whole lot of fairly ambitious goals laid out to try and develop new processes, and redistribute funds at very aggressive timelines. It’s debatable to my mind whether these timelines will be met. (To be clear it is ALWAYS the Ministry team that is unable to meet the time lines, the OMA staff gets things done in time).

The Ugly:

One per cent increase per year?? In a time when inflation is 5.7%??

I suggest physicians access the contract and reading materials the OMA staff has put together. The staff have done an excellent job explaining the agreement and putting together a list of FAQs for you to review.

Additionally, if you are interested in more of a “big picture” approach about how to review the agreement as a complete package, my friend Paul Hacker has put together a truly excellent, easy to read, and for him quite short, document here.

I’m not going to write about any of that stuff. Rather, I’m going to write about the process to reach the agreement, and why after considering that, I personally am going to vote in favour. However, I do reserve the right to pinch my nose while doing so.

The negotiation process between physicians and government is laid out in the Binding Arbitration Framework (BAF). The short version is that it requires the government and OMA to start negotiating at least six months before a current agreement expires. It also sets guidelines for minimum time limits for how long negotiations can go on before moving to the next stage (e.g. mediation and arbitration). This time round of course, none of those timelines could be met because of the Covid Pandemic. Everything got pushed back (by mutual consent of both parties).

What is it about the process this time round that makes me want to support the PPSA? Let’s face it, nobody out there, myself included, is calling this a great agreement. So why support it?

Firstly, the government once again opened negotiations with a pretty lowball offer. Not sure how much I can say about the confidential negotiations process, but given the OMA negotiations team has already indicated there was a wide gap to start, and given we didn’t reach an agreement until invoking mediation, well, let’s just say there was a pretty big difference between the two sides to start.

Second, the Mediator (Mr. William Kaplan) is also the Arbitrator if we turn down the agreement, and head to Arbitration. I know, I know, the BAF states that there has to be an Arbitration “panel.” But the reality is the panel has a government appointee (Kevin Smith) and an OMA appointee (Ron Pink) and lastly Kaplan himself. I think it’s obvious who would make the final decision in such a circumstance.

In the 2018 negotiations, the government and OMA were unable to agree to an acceptable deal even through mediation. So we had no choice but to go for Arbitration. On this occasion, while many will argue that the OMA should have held out for more, the reality is that the OMA’s team also spent a lot of time with Kaplan. Got a sense of what he’s thinking, and what he’s looking at.

There’s no guarantee of what he would do in Arbitration of course. I’ve met Kaplan. I think I’d have more luck interpreting the emotions of a stone wall than him. He’s a tough guy to read. That’s probably an important skill to have when you are a mediator/arbitrator. But the OMAs negotiations team is really good at “reading the room” based on decisions Kaplan has made (e.g. extending the timelines and so on) during this process.

The choice then, to my mind, is pretty simple. We can vote for this agreement, as unpalatable as it may seem to many, and get on with implementing some of the benefits. Live to fight another day.

Or we can reject the PPSA. Which means we go to Arbitration. At which point both sides will likely revert to their opening positions in negotiations. Thing is, we already, by virtue of the having a mediated PPSA, have some insight into what the Arbitrator is thinking. To my mind, rejecting this agreement will simply kick things down the road six months (or more) at which point we will not get anything better.

My personal feeling is it’s time to move on. I’m going to vote in favour. I encourage all of you to read the briefs from the staff, and make your own decision.

Covid is Not Over – and It Won’t EVER Be

As provinces across Canada begin to lift restrictions from the Covid pandemic, there is a plethora of opinions raging about this. Some physicians feel the restrictions are being lifted too slowly. Others feel that it is just right. In Ontario at least, the most outspoken group are the physicians who demand ongoing restrictions. They have taken to using #Covidisnotover on Twitter.

Obviously, when dealing with a once in a century pandemic that has truly decimated patients and health care workers alike, there are still going to be unknowns going forward. But personally speaking, I think we have to realize a couple of things. First, Covid is not over. Second, and most importantly, it never will be.

Is the flu over? Is HIV over? Heck, are measles and RSV over? The answer to all of those is no. The viruses are still around, they are still infecting people and are mutating all the time (that’s why we need an annual flu shot).

There are always a certain amount of these viruses in the ecosystem. Why would Covid be any different? We are not going to completely eradicate Covid.

Given this – the question becomes, what do we do as a society?

One option, and certainly one that is promoted by the #covidisnotover types, is to continue ongoing restrictions, for much longer. Be it mask mandates, enforced vaccine passports, or continued limits on indoor capacity, the message from them seems to be to keep imposing restrictions for……well, I couldn’t really find consensus on an end date.

The most common argument for continuing restrictions (in Ontario anyway) is the continued positive case load. There are more positive cases than ever before, so why should we stop restrictions now?

Well, the short version is that while it is absolutely true that our case load is higher now than in, say October of 2020, many other factors have changed. In October of 2020, there were no vaccines. There were no oral medications that could help treat those who were infected. Guidance on the fact that Covid is airborne was still (shockingly) lacking.

In comparison, in March of 2022 over 90% of the adult population of Ontario has two covid vaccines, and are well on the way to their third. Evidence is clear that the vaccines are remarkably effective at preventing serious complications of Covid. There is now a strong emphasis on good ventilation as a way to reduce the Covid burden. The government is providing funding for Hepa filters in schools and child care settings. A protocol for rolling out the new oral medications exists, and, like all things, supply of the medications will increase with time.

So to compare just case numbers from October 2020 to March 2022, quite frankly is just comparing apples to oranges. We need to take all these other factors into account.

The other common argument is essentially “Look at Denmark!“. Pro restriction types point to the fact that Denmark lifted all Covid restrictions on February 1st, 2022, and now seems to have an exploding number of cases and mortality. Graphs like the one below are designed to shock people into thinking there is a catastrophe in Denmark:

But the graph doesn’t tell the whole story, and in fact a much more nuanced approach requiring a deep dive into the data is needed. I was going to try but I can’t do a better job of it than Michael Petersen did in his twitter thread:

The short version is that because so many people have Covid now, we need to do a better job of determining who died because of a covid infection (usually a covid pneumonia) vs who died of other causes, but incidentally happened to have Covid at the same time. A better graph showing the Denmark situation (taken from Petersen’s thread) taking this into account is here:

Before people start jumping all over this, let me also point out that I am acutely aware that there is a significant spike in deaths in Denmark recently, even if not specifically caused by Covid. We clearly need to do a deeper dive into why there were excess deaths. But part of that deeper dive must include whether deaths were caused by the restrictions themselves (delayed care, depression and mental health issues leading to people just giving up etc). In essence, is the cure (restrictions) causing more harm than the disease (Covid)?

Look, lockdowns and restrictions were initially necessary. There is good evidence that they helped to blunt the course of Covid. But there is also evidence that they have harmed society as well. The economic impacts with record government deficits that will tax our great grand children are well known. However, there are also other health care impacts.

In Ontario, we have a back log of 20 million health care services, leaving many patients feeling forgotten. There are consequences to delayed care and I have seen that in my own practice, and expect to see much more in the coming year. Yes, those consequences sadly will include deaths.

All of this is before we even consider the collateral damage done to mental health especially in our pediatric population. As Dr. Jetelina points out in her excellent sub stack, there has been a world wide increase in paediatric mental health issues. A 24-31% rise in children presenting with mental health issues and a shocking 69-133% (depending on age group) increase in children presenting with suicidal thoughts to Emergency Departments.

What does all this mean?

My personal feeling is that while we cannot ignore Covid (it’s a bad disease) and we need to continue to encourage vaccinations (they work), we need to start looking at the health care system as a whole. Should we mask in high risk areas? Sure. But should we continue to isolate people socially and restrict interactions in a lower risk population, when that clearly causes other harms? I would argue no.

We have been making decisions for a long time based on Covid numbers alone. There are other illnesses and disease that are out there, many of which have been worsened by the restrictions Covid has forced on us. We need to start basing our health care decisions on what’s best for overall population health, not just Covid.

Crisis at Trillium Health Partners Demands an Intervention

Over 20 years ago, I and a number of other physicians were involved in a significant dispute with our local hospital administration. The specifics don’t really matter now (it’s ancient history). But in general terms physicians like myself felt strongly that we were fighting for patient care against an administration that didn’t value our input or opinion. Administration at the time undoubtedly felt differently. Eventually, both sides became entrenched and the Ministry of Health had to send in a team to sort this out, after we went public with our concerns. The MOH bureaucrat even fashioned a new phrase, referring to their team as “Interveners”.

All of which is to say I still get nightmares when I hear of in house disputes at a hospital being made public, most recently at Trillium Health Partners in Mississauga. Not working at that hospital, all I can go on is what CTV News reported. 40 physicians at Trillium Health Partners have hired a lawyer alleging:

  • physicians “are targets of an abusive and unprofessional behaviour of the hospital administration.”
  • “terrified for their livelihoods”
  • “fearful to go work”
  • a physician was called “crazy”
  • “a toxic culture rooted in harassment, intimidation and threats”
  • an environment where “physicians are afraid to practice medicine”

All of this certainly brought back my own PTSD at the events that led myself and my colleagues to take action over two decades ago.

As mentioned, I don’t know the specifics there. But I can say a few things in general from not only my previous experience, but from other institutions where I’m aware of doctors speaking out.

First, doctors in general hate speaking to the media and going public about internal conflicts. It’s one thing to talk about medical issues that pertain to the health care needs of the population as a whole. But to go out and air dirty laundry? It’s not in their nature. For something to reach this point, it usually means that every possible avenue has been exhausted, and there is a real concern for patient care.

Second, every hospital has multiple processes for addressing concerns. There’s a Medical (or Professional) Staff Association that advocates for the needs of their professional staff. There are numerous committee structures and depending on the concern the issues can be brought there. There are internal complaints processes and various Human Resource department protocols. There are chiefs of departments whose role includes addressing concerns fairly. Basically a lot of ways to bring problems to the attention of the higher ups.

Third, doctors in general put up with a lot of bureaucratic non-sense just so they can get the job of looking after patients done. Whether it’s ludicrously difficult hospital IT systems, policies that require us to duplicate our efforts, or any number of roadblocks, physicians complain privately about the working environment, but put up with it because we want patients well looked after.

In that context – to see physicians do what they’ve done, and write to the Minister demanding she appoint a supervisor (essentially someone to take over the administration of the hospital) signals a complete failure of all of the internal processes, and a dramatic escalation. This only happens when the two sides are entrenched.

What next?

What’s Likely to Happen:

Usually, administrations in such a situation tend to circle the wagons and go on the defensive. Attempts are made to minimize the concerns or denigrate the physicians as a small group not representative of the whole. Evidence is produced suggesting the concerns were appropriately reviewed and dealt with.

As an aside, Trillium has already done this by having their own lawyer investigate the complaints and, surprise surprise, the lawyer Trillium pays found Trillium did nothing wrong. I would have thought for issues of this magnitude it would be appropriate to bring in an external person to review. Maybe Trillium didn’t do anything wrong. But surely having an external person say that would carry more weight.

Then, if physicians make enough noise, the issues continue to percolate, the general public expresses concern and politicians get scared. In our area, the issue became so toxic that enough physicians decided to resign their privileges and our Emergency Department was in danger of shutting down part time.

After months of agony, somebody at the MOH (plus/minus political intervention) realizes they have to do something and appoints a third party with the power to actually do something and make some necessary changes.

What Should Happen:

Why go through additional months of grief? There’s clearly a crisis there. The residents of the catchment area of the hospital must surely have concerns about the care they will receive when they read the articles from CTV News. Having doctors who are fearful of the working environment simply cannot contribute to good patient care.

The MOH appointed their “Intervener” in my hospital and the Intervener had the power to tell both Administration and Physicians when they were offside. I personally got told I was going too far offside by him during the process, and I know Admin was also told they had to back down on some things. At least he was fair.

I don’t know who’s right and who’s wrong at Trillium, but patients at Trillium need to know that something is being done to address these concerns and ensure there is safe environment for the caregivers. To that end, the MOH needs to appoint an independent third party to help the situation sooner, rather than later.

For a link to CTV News’ follow up report on the issues that includes comments from yours truly, click here.

Corporatization of Medicine Continues Unabated

Last week, a story came across my feed that seems to have been almost completely ignored by most who are in/or follow medicine and health systems. WELL Health technologies announced that it has purchased 100% of CognisantMD, the developers of the Ocean platform. For those who don’t know, Ocean is a platform that links to various EMRs and allows for securely emailing patients, eReferrals, filling out forms online, and a bunch of other features.

Full disclosure, my practice uses Ocean as well (for now). Personally I find it somewhat clunky and not as smooth as advertised, but there are some positive features to it.

What’s the problem then? It’s a friendly corporate takeover. Happens all the time in the business world.

To understand the concerns, let’s look at what WELL Health does. According to their own website, WELL Health offers a wide array of digital health care solutions. But they also state they are “Canada’s largest outpatient medical clinic owner-operator and leading multi-disciplinary telehealth service provider”. In essence, they run the clinics, and physicians work for them.

A further dive into their strategy, under the “Reinvest” tab states:

“Acquisition of cash generating companies leads to increased cash flows which are re-invested to make additional new cash generating acquisitions.”

Pure and simple – WELL Health is a private, for profit corporation. There is of course, nothing wrong with private corporations. Most people who follow my twitter feed know that I am generally pro-business, and on most issues land on the right side of the political spectrum. I firmly believe we need more, not less, businesses in this country and we need to make it easier for businesses to function.

BUT – acquisitions like these, and the continued take over of clinics by corporations should make us ask legitimate questions about protection of individual health care data. It is no secret that the reasons that companies like Google and Facebook have become so successful is that they found a way to monetize personal data. In much the same way, personal health care data has enormous economic value to companies. Whoever can find a way to properly monetize this, will be the next Jeff Bezos/Mark Zuckerberg and so it’s no wonder that companies are extremely interested in getting into this field.

As I mentioned in a previous blog, Shoppers Drug Mart, for example, recently acquired a stake in Maple, a leading virtual care only provider for $75 million. They continue to advertise on their website (as of Dec 6, 2021) the ability to diagnose strep throat virtually (which personally I find questionable) and then to send antibiotics to a pharmacy near you (I’m guessing there is going to be a Shoppers Drug Mart near you).

Screen shot as of Dec 6, 2021

In a circumstance where a patient contacts Maple, the doctor or NP gets paid to virtually assess a patient, Maple gets a percentage of the fee to cover overhead – which presumably will be reflected in shareholder value to Shoppers. If a prescription gets sent to a Shoppers, well, they make a profit there too. Neat business model.

But it’s not just companies that already have an interest in providing health care related services that are trying to get involved in this field. Amazon is jumping into health care with a telemedicine initiative. Google has long planned to get into health care, and while not terribly successful yet, I doubt they will stop trying. Heck even Uber (!) wants to get involved in health care.

It’s easy to see why everyone wants in. There is a lot of money and potential profit in health care. And while I am all for companies making a profit, that doesn’t mean that we can’t ask some hard questions about the protection of personal health care data such as:

  • How secure is the data that is being held in the servers owned by these corporations?
  • How do we ensure personal health data doesn’t go where it’s not authorized? (eg. supposing the parent company owned a family practice clinic AND an disability insurance company)
  • How do we ensure personal health data is not to be used to monetize other aspects of a business (eg. supposing a walk-in clinic was owned by a pharmacy. A patient attends there for a renewal of cholesterol medications, and then gets ads offering, say, flax seed oil capsules that are helpfully sold by that same pharmacy).
  • How do we ensure aggregate health data housed in those servers is only used to help the community at large (eg. finding communities that may need extra resources for, say opiod addiction).
  • If a physician stops working at a clinic owned by MegaCorp Inc. for whatever reason, how does that physician access their charts after the fact (I’m aware of a number of cases where access to patient records were cut off immediately upon the physician leaving such a clinic).

I’ve just posited a few questions. I’m sure there are many more. I believe that most Canadians strongly value health care privacy. As more and more businesses attempt to get involved in health care delivery, it is vital that we have a framework for oversight that ensures that patients have the absolute right to protect their personal health information. Sadly, I don’t see any organization/government agency out there asking these important questions.

Time for the OMA Board to Invoke Arbitration in Stalled Negotiations

While most front line physicians continue to deal with the ongoing Covid-19 pandemic, and the resultant backlog of care, the OMA has continued to perform it’s most important function, that of trying to negotiate a Physician Services Agreement (PSA). A quick summary of what has already been disclosed:

  • The Binding Arbitration Framework (BAF) between the Ontario Government allows for negotiating a Physician Services Agreement (PSA) every four years. The last one was for 2017-2021 . We should already have had an agreement for 2021-2025 but the Covid Pandemic got in the way and delayed negotiations.
  • Negotiations for a PSA are supposed to start the year before expiry of a PSA. There is a framework that allows for a minimum of 60 days for negotiations following which either side can call for mediation. After a minimum of 60 days of mediation, either side (or the mediator) can call for Arbitration.
  • IF Arbitration does occur, the Arbitrator must hand down a ruling within 60 days of the conclusion of the arguments presented at Arbitration. After the ruling is handed down, the work of implementing the Award (or if by some chance an agreement is reached – the PSA) begins, and that in itself can take several months to a year. Those of us who were involved in the last implementation process in any way likely still have nightmares about how complex and fraught with challenges it was – I know I still do.

For the current negotiations, we know the following:

  • Negotiations began in October of 2020. The OMA Board gave the Negotiations Task Force (NTF) a mandate for negotiations. A mandate is essentially a confidential, bare minimum set of asks that the NTF must get from the government before accepting a deal. Considering there is no deal, the NTF clearly has not met that minimum. And no, the members can’t know what that is, it would significantly compromise the negotiations process.
  • Mediation began on April 9, 2021. “A large gap” remained between the OMA’s asks, and the MOH’s offer as of June 2021. As I’m no longer on the OMA Board, I have no idea what the gap is like now. Obviously, if there was no gap, we would have a deal by now.

Why should the OMA Board move to Arbitration now? Why not follow the mediator Mr. Kaplan’s recommendation, and wait till January 25, 2022 to go to Arbitration? Wouldn’t going against his recommendation run the risk of adversely affecting the outcome of a potential award?

Because health care is political in Canada. Being political, the time for governments to attack physicians is always, always, always early in their new mandate. In 1991, the NDP government of Bob Rae imposed a hard cap on the physicians budget (first year in power). In 2015 in the first year of Kathleen Wynne’s government, she also imposed unilteral cuts to physicians and in 2018 the Doug Ford government tried to take away binding arbitration.

The short version of the above is that I’m old, and I’ve been screwed by the government of every political party. It doesn’t matter who wins the provincial election of June 2022, the government that is in power will be sorely tempted to revoke any arbitration award if it seems to meet their short term interests. (Yes I know, the BAF is “evergreen” – meaning the process should continue in perpetuity, but the reality is that governments do stupid things all the time, and if one government has tried to take away a BAF process from physicians to suit their interests, then we can be sure another will as well).

And NO, having Arbitration currently as scheduled for Jan to March 2022 is not good enough. Finishing Arbitration hearings at the end of March gives the Arbitrator until the end of May for a ruling. By that time the election campaign will be in full gear, and Ministry bureaucrats will do absolutely nothing to implement any award as they wait for the outcome of the election.

Obviously, going to Arbitration now entails some risks. The NTF will likely argue that the Arbitrator himself recommended waiting till January, and we should try our best to seem reasonable to him. I have a great deal of respect for the NTF for the job they’ve done for the doctors of Ontario, in particular the negotiation of the BAF. But they are paid a lot of (well deserved) money to let the Arbitrator know of legitimate concerns of the membership.

I’ve met the Arbitrator and I have no doubt he will hand down a fair decision, whether in December or March. But members have every reason based on history to fear politicians of all stripes, and it’s the job of the NTF to let him know that that’s a legitimate concern.

Moving to Arbitration immediately, means the Arbitration hearings end likely by the end of December. An Award is announced (likely) by March. At that point, the government is faced with accepting the award, or revoking it three months before an election, and risking the type of anti-government ads the OMA did so well last time. By the time the election is over, whoever wins, the MOH bureaucrats will be well on the way to implementing the award and any “noise” that the award is too much (there will always be noise) will have gone away.

From the OMA’s Negotiations Page

The OMA’s main responsibility is to negotiate a fair PSA for members. The BAF is the best tool they have for not only keeping the government honest, but for political use to reduce the risk of awards being overturned. (NB- There’s no guarantee of anything, politicians do stupid things all the time. This is simply about risk reduction).

Will the OMA Board stand up for members and direct the NTF to immediately move to Arbitration, as we are now legally allowed to? I guess we’re going to find out.

Vaccine Certificates/Mandatory Immunizations are a Bad Idea

First things first, if you’ve read the title of this blog, and are hoping to find ammunition to promote a vaccine hesitant agenda, you won’t find it here. Go watch Fox News or Newsmax or any other QAnon affiliated vaccine disinformation service.

The COVID vaccines are safe and they are incredibly effective. Something like 99.5% of all patients in hospital ICUs with COVID are people who have not been fully immunized. Many of them beg to get immunized after getting sick, but by then it’s too late.

Frankly, I think an argument could be made that the mRNA COVID vaccines are the most effective vaccines science has ever developed. If you remember nothing else from this blog – remember this – I encourage you to all voluntarily get vaccinated for COVID, especially now that we seem to have adequate supplies.

Making vaccines mandatory/vaccine certificates however, introduce a whole new set of concerns that I don’t think have been well thought out.

The rationale for introducing Vaccine Passports/Certificates appears to be to protect society. By requiring documentation that you have been vaccinated prior to allowing you to go to a restaurant/travel in Canada/attend sporting events etc, the thinking is that you will prevent the spread of COVID.

The argument for making COVID vaccinations mandatory for health care workers is that patients should feel safe when accessing health care, and be assured they won’t get COVID19 from someone who is treating them. The point has also been made that health care workers are often required to show proof of immunity to things like Hepatitis B and Tuberculosis. So why not add COVID to the list? (Interestingly, those who espouse this view conveniently forget that health care workers are not required to immunize yearly for the flu, and the flu kills far more people every year than either TB or Hep B).

But.

One thing this pandemic has taught us, is that there is a small group of people out there who are extremely mistrustful of authority. They won’t trust doctors/public health officials/nurses etc. They prefer to do their own “research”. Their “research” is frankly guided by confirmation bias (looking only at information that supports your agenda, as opposed to looking at all the facts, whether supportive or not). These people then (sadly very successfully) use social media to spread their half truths (and in the case of noted health experts Donald Trump and Tucker Carlson – outright lies).

The damage caused by these people is in calculable. COVID appears to be resurgent in the United States and is being (rightfully) called a pandemic of the unvaccinated. Third world countries are struggling with another wave, and are desperately trying to keep their health systems afloat, while they get the needed vaccines. International travel remains in limbo, and the economic damage caused worsens by the day.

So why then are vaccine certificates or mandatory vaccinations for health care workers a bad idea?

Because no matter what I or other health officials think of the idea, the simple reality is that the vaccine hesitant crowd will spin this as co-ercion.

Celebrated Infectious Disease Specialist Marjorie Taylor Greene discusses the pros of Covid Vaccination (sarcasm fully intended by writer)

And that, in a nutshell, is why I oppose the idea of vaccine certificates, and mandatory vaccinations. We have the weight of evidence on our side that vaccines work. We have been able to debunk many of the stories about the COVID vaccines (remember when the Pfizer vaccine was going to cause an outbreak of Bell’s Palsy and we were all going to walk around with half droopy faces?). With each passing day seeing only unvaccinated people being admitted to hospital with severe COVID we keep building our case. We should be pro-actively promoting all of this in order to let the vaccine hesitant know that their concerns are unfounded.

One thing that has been badly done during this pandemic is the dissemination of information. In any crisis, the first thing to do, should be to have clear, consistent, factually accurate communication. This has been sorely lacking in the past 16 months with health authorities disagreeing with each other.

Yet now, we are again running the risk of doing the same thing. On the one hand, we’ve got experts (quite correctly) proclaiming the vaccines are the best way to prevent COVID.

And now health authorities are turning around and essentially saying ” yah, but we’re going to make you have a special passport to go anywhere so you are protected.”

What exactly do you think those that are already suspicious of authority are going to think? They are simply going to double down on their belief that we have to be “forced” into getting a vaccine, because it’s really not as good as we say it is. We’re going to lose any chance of trying to build bridges with the vaccine hesitant crowd, and win them over with the force of reason and facts (which is overwhelmingly on the side of those who believe in vaccinations).

The whole point of taking the incredibly effective COVID vaccines, is so you can go places and NOT WORRY if the other person is unvaccinated. Even if you are exposed to COVID, it will be the unfortunate misguided unvaccinated individual who will get sick, not you.

Building trust with the vaccine hesitant crowd is hard. It takes time, effort, repetition of facts and a calm approach. But if we go down the road of creating the impression of co-ercion, we’re going to embolden hesitancy and create more fear and mistrust. Vaccine hesitancy will only rise as a result and mistrust of health authorities will increase. Who knows what the long term implications of that are? I worry those implications will last beyond the pandemic, and will cause ongoing problems for health care in the future.

We have facts/reason/data to support the COVID vaccines. Let’s keep promoting that, and not give those who mistrust health authorities, more ammunition.

Tone Deaf CFPC Fails Its Members, Embarrasses Itself

Recently, in what seems to these old eyes to be an insulting, vindictive and offensive move, Canadian Family Physician, the “Official Journal of The College of Family Physicians of Canada (CFPC)”, published a hit piece on Family Doctors that only serves to further demoralize and dishearten a beaten down profession. I cannot fathom the amount of, what at best could be described as political naïveté, and at worst a disconnected Ivory Tower mentality that would be required to write such a venomous attack on those who actually pay money to keep their organization going.

Seriously, what was the CFPC thinking when they okayed Roger Ladouceur’s editorial, titled “Family Medicine is not a Business.”?? (I refuse to link to it as I don’t want it to get any more hits).

Truly, it’s not really an editorial, rather a massive litany of complaints against family physicians, while sarcastically suggesting “surely, it’s just gossip!”

What exactly are evil rotten family doctors doing according to Ladouceur? He suggests the CFPC has “heard stories” about family doctors not seeing patients in person and wondering how they can assess complicated patients. He has “heard stories” about doctors only calling patients at more lucrative times and abandoning patients with high medical needs. He has “heard stories” about family doctors “charging excessive fees” for services not covered by health insurance.

He ends off his purulent missive by blithely stating, “Family Practice is not a business.” Marie (“Let them eat cake”) Antoinette would have been proud of such a comment, dismissively heaped on the approximately 40,000 overworked family doctors in Canada.

There’s a lot to unpack in Ladouceur’s diatribe. First and foremost is the fact that despite extolling the virtues of evidence based medicine, the CFPC allowed an editorial to run that had, well, no evidence to back it up. The whole argument was based on “I have heard stories.” There are no numbers to back it up, no names of offending physicians, no statistics on how widespread these alleged problems are. Just gossip and innuendo based on what he has “heard.”

If you want evidence by the way, I can confirm that the OMA Board was told that based on OHIP billing data over 98% of family doctors in Ontario continued to work after the pandemic was declared. It is true that they are using a mix of virtual and in person visits, but given the need to social distance during these times, a mix is clearly the correct way to proceed.

Furthermore, the banal statement that “Family Medicine is not a business” is simply factually incorrect, and reveals a kind of ignorant, Ivory Tower mentality that shows a complete disconnect from the real world.

Let me be clear about this, I consider myself one of the lucky ones. My family has food on the table. We have a roof over our head. There is no danger of my car being re-possessed. I’m fortunate compared to the average Canadian and am extremely grateful to be in that position.

But while I genuinely enjoy seeing my patients (they’re a great bunch of people), I still have to pay my staff, order supplies, pay rent and utilities, ensure my computers are working properly, get payroll taxes paid, comply with labour legislation etc etc. In short, while we all hate to think about this side of things, Family Medicine has been, and will continue to be a business of some sort. That the CFPC would allow such an obtuse comment by Ladouceur to run, shows a wanton disregard, and, dare I say it, contempt for the many day to day issues that its members face.

Look, no physician likes seeing one of their organizations scold them (and certainly I will always push back when I see this kind of stuff happening), but I really have to wonder just how completely out of touch the CFPC must be to allow this type of berating in the middle of the biggest physician burn out crisis I have ever seen. Prior to the pandemic, 26 % of physicians were clinically burnt out, 34% were suffering from a degree of depression and over 50% reported some symptoms of the burn out. Exactly what do you think has happened to those numbers after the pandemic? Especially with physicians recognizing that even though we seem to be coming out of the pandemic, there is an overwhelming backlog of delayed care to address?

Yet amongst this backdrop, here comes the CFPC, not to try to find ways to support physicians or provide tools to help them be healthy so they can look after their patients better, but to berate, admonish and vilify them as a group. This is supposed to make things better??

The type of evidence free invective Ladouceur ran should never have been given any platform, much less a platform on an organization who’s mission statement includes advocacy on the part of the specialty of Family Medicine. Frankly, I’m embarrassed to be a member of the CFPC, though given the regulatory requirements to maintain my continuing medical education, I can’t resign from it.

If the CFPC really wants to help, they will pull Ladouceur’s screed from their magazine, and apologize to all 40,000 Family Physicians in Canada. Anything less will suggest complicity and sympathy with his views, and will contribute to Family Physicians losing confidence in the CFPC.

Let’s Discuss the Astra Zeneca Covid Vaccine

The following blog is written by Dr. Anne-Marie Zajdlik, MD, CCFP. She is the founder of ARCH Clinic Guelph and Waterloo, Founding Director of Bracelet of Hope and Founder of the Hope Health Centre

Let’s discuss the AstraZeneca vaccine.  I am just going to give you some facts.  You can make your own decision about the AstraZeneca vaccine.

On March 29th,  Canada’s National Advisory Committee on Immunization (NACI) recommended provinces pause on the use of the AstraZeneca-Oxford COVID-19 vaccine on those under the age of 55 because of safety concerns. NACI’s priority is vaccine safety.   Their decision came after the European Medicines Agency ( EMA), Europe’s Health Canada equivalent, investigated 25 cases of very rare blood clots out of about 20 million AstraZeneca vaccines given.  On March 18th the EMA concluded that the benefits of the AstraZeneca vaccine far outweigh this risk if there is a true increased risk of the blood clots.

Most of these rare blood clots occurred in women under the age of 55 ( 18 out of 25).  Thus, NACI’s recommendation to halt the use of the AZ vaccine in this age group pending further review of the ongoing real-time research.

So, 25 cases out of 20 million vaccinations is a risk of about 1 in a million.  That means that if there actually is an increased risk, the risk is 1 case of the rare blood clots out of 1 million vaccines given. One in a million.

Let’s shed some light on that: The risk of blood clots developing among new users of oral contraceptive pills ( birth control pills) is 8 out of 10,000. Thirty four out of 10,000 women who use  hormone replacement therapy ( HRT ) will develop a blood clot at some point.  And, the risk of developing a blood clot in women in general  is is 16/100,000. 

The Canadian maternal mortality rate ( the rate of death in women during childbirth) is 8.3 deaths per 100,000.

No medical intervention is without risks.  The question is, should we take that risk?  That is what NACI will try to figure out in the coming weeks. Let’s balance that risk of 1 in a million with the risk of COVID-19. 

A new briefing note from a panel of science experts advising the Ontario government on COVID-19 shows a province at a tipping point. Variants that are more deadly are circulating widely, new daily infections have reached the same number at the height of the second wave, and the number of people hospitalized is now more than 20 per cent higher than at the start of the last province-wide lockdown.

These variants are more dangerous and more easily transmitted.  They cause 2.5 to 4.1 deaths per 1000 detected cases.  That’s deaths.  The risk of serious complications with the variants is double the risk of the original COVID-19 virus:  20 out of 100.

Here’s a quote that scared me.  “Right now in Ontario, the pandemic is completely out of control,” Dr. Peter Juni, the scientific director and a professor of medicine and epidemiology with the University of Toronto and member of Ontario’s COVID-19 science advisory table.

The AstraZeneca vaccine is over 70% effective up front and almost 100% effective at preventing deaths and hospitalizations from COVID-19. Breathe.  It is not time to throw out the baby with the bath water.  No blood clots have occurred in people over 60.  We should continue using the AstraZeneca vaccine in this age group which is most at risk of serious complications and death from COVID-19.

Alberta Doctors Should Reject the Tentative Agreement

Disclaimer: Just a reminder that, once again, I am not speaking on behalf of the Ontario Medical Association. The opinions expressed in this blog are mine, and mine alone.

Many who read this will wonder why I’m talking about a potential physicians agreement in another province. Some will point to my role at the Ontario Medical Association (OMA) as past-president and suggest that I should stay out of the affairs of another Provincial, Territorial Medical Association (PTMA). Normally I would. But the situation in Alberta has implications for physicians across the country, including Ontario, so I feel compelled to speak out. Besides, considering the then President of the Alberta Medical Association (AMA) commented on our own tentative agreement in 2016 (and he was right by the way), I think it’s ok for me to speak out as well.

I don’t know all the details about the ins and outs of how the AMA works, nor do I know all minutiae about their negotiations process.

But I know when doctors are getting screwed by a government.

Alberta Health Minister Tyler Shandro

Last week, the Alberta Medical Association (AMA), announced a tentative agreement with their government. The agreement allows their volatile, combustible Health Minister Tyler Shandro almost unlimited, and truly unprecedented power over Alberta Physicians:

  • It reduces their physician pay to 2018 levels
  • It gives the temperamental Shandro Ultimate authority over how much physicians get paid. Just read this truly scary statement by the AMA:

“The AMA acknowledges that the physician services budget is established by the minister in the minister’s sole discretion,” it states.

“The AMA further acknowledges that nothing in this agreement fetters the minister’s authority or discretion with respect to the physician services budget.”

  • It places a hard cap on the physicians services budget, meaning that if the demand for care went up above the predicted level, physicians incomes would be clawed back to make up the difference. As an aside, demand will almost certainly exceed the projections. We are coming out of a pandemic and are facing an enormous backlog of care. How eager do you think the volatile Shandro will be to allow an overage of the physicians service budget going forward?
  • Worse, the AMA is required to discontinue their lawsuit demanding binding arbitration, which all physicians should view as an inherent right.

For me personally, the whole Alberta situation has brought back some particularly bad memories. In 2012 the OMA accepted a 0.5% fee cut in the hopes that appeasement of a bullying government would lead to better things in the future. This of course is not the way to stand up to bullies, and Ontario physicians felt the brunt of this as the now second worst health minister I have ever seen, “Unilateral Eric” Hoskins, sensing weakness, imposed unilateral cuts to physicians in 2015.

After a couple of years of internecine warfare, the OMA and Unilateral Eric came to a tentative agreement in 2016 as well. That agreement:

  • Reduced physicians pay to levels from a few years back setting a lower base rate for the Physician Service Budget
  • Allowed for a hard cap on physicians billing
  • Allowed the Health Minister to claw back physicians billings if usage exceeded projections

Sound familiar? At least the Ontario agreement allowed our own Charter Challenge on Binding Arbitration to continue (which it painfully, slowly does to this day).

We were told by the OMA Board at the time that this agreement was the “best that could be done” and that we were going be faced with even more clawbacks and cuts if we turned it down. As is well known now, the agreement was soundly rejected, the increased clawbacks never materialized and when faced with the prospect of an election, the government of then Premier Kathleen Wynne finally had to recognize that Arbitration was an inherent right for all essential workers, physicians included, and we secured a fair Binding Arbitration Framework.

All of which is my way of encouraging Alberta Physicians to realize that they don’t have to simply roll over and accept the “best we can get”. While there will be some pain in rejecting the agreement, at the end of the day, governments need to go to the polls. That’s when having angry doctors makes them vulnerable. It will not be pleasant to hold out, and say no (it certainly wasn’t in Ontario!) but I submit that it is better to keep your integrity intact and stand up to a patently unfair deal.

But wait, what about these implications for physicians across Canada I referred to? It all has to do with negotiations.

Obviously, I can’t talk in detail about negotiations. BUT, what I can confirm is what many of us have long suspected. Bureaucrats from Provincial Governments talk to each other all the time. They share data. They share information, and they share tactics. They may or may not (depending on their political masters) use a particular tactic/program/scheme etc, but they do share.

Which means, that IF Alberta docs pass an agreement like this, which chains them to a hard cap and allows even a minister as incendiary as Shandro, free, unfettered reign, then we can expect other governments to attempt this as well. “Your colleagues in Alberta accepted this, why can’t you be as reasonable and co-operative as them?”will be the opening position in negotiations in many provinces after this.

That is why physicians across the country should follow the situation in Alberta with interest. That is why we should support our Alberta colleagues. That is why, for the sake of physicians in Alberta, and everywhere in Canada, this deal needs to be rejected.

If you want more, a colleague has prepared a helpful Q&A about our situation, and you can access it here.