How to Feminism

The following is a guest blog written by Dr. Darren Cargill, pictured above Opinions are his. Especially what he wrote about Nik.

Like most of you I enjoyed Sarah Cooper’s savage tweets and parodies of Donald Trump during the lockdown.  From “How to Testing” to “How to Empty Seat,” she has entertained people around the world during difficult times.

But her tweets also got me thinking about feminism and the female role models I have had throughout my life and medical career.

Currently, the most recognizable feminist “role model” (stop laughing) in Canada is best known for firing our first Indigenous Attorney General and forcing out of Cabinet a physician who might been useful going through the COVID global pandemic.  He used his power and privilege to prevent them from speaking the truth about what actually happen.  He also yelled at a racialized MP who had chosen to step down, admonishing her for not appreciating all he, a self-admitted privileged white male, had done for her.  And his socks.

This doesn’t seem right.  Clearly, I am experiencing feminism differently.  If so, it seems like there is still lots of learning WE can do.  I needed to learn more.

So I did.  In the process, I read and heard a lot about something called the “gender pay gap.”  I didn’t know a lot about it, so I asked some colleagues of mine to explain it to me and what could possibly be done to remedy the issue.  

So instead of looking to our political leaders to set the example, I decided to look back at my own life and career instead.

First, I am very proud of the fact the Section of Palliative Medicine currently boasts only the second ever (damn you Genetics) all-female Executive for a clinical section.  As Section Chair for seven years, I have never had more confidence in the future leadership of our group.  This executive was not contrived or selected like some associations or cartels.  All three ran in open elections for our Section leadership.  Although we have had some great leaders for our Section in the past, our future has never been brighter.

One of my absolute favourite memories of the pandemic lockdown was Dr. Wendy Kennette doing an Executive teleconference from the Windsor Mobile Field House at St. Clair College in full PPE.  Nothing more needs to be said about her single-minded determination and commitment to compassionate patient care.  Except, it should be acknowledged that she also led the charge to create Windsor’s first permanent inpatient palliative medicine program at Windsor Regional Hospital. Dr. Pamela Liao has been exceptional in her first year as Section Chair.  She routinely leads from the front and regularly organized and participated in webinars to inform and educate members during the early days of COVID.  Finally, Dr. Patricia Valcke has stepped in as a first-time member of the Executive in the role Secretary/Treasurer after relocation from Saskatchewan to Ontario. She has hit the ground running as the new co-chair of the Schulich School of Medicine Enhanced Skills Program for Palliative Medicine, taking over from Dr. Sheri Bergeron.  I look forward to her bright future in leadership as well.  

Next, like most little boys, my first role model was my mom.  She recently retired at the age of 75.  She broke her leg in May, spent three months in rehab, most of that non-weight bearing, yet walked New York City by Thanksgiving (Canadian, not American for the record).  After all, she’s Dutch.  Wooden shoes, wooden head, wouldn’t listen, as they say.

I had many wonderful female teachers growing up.  But during elementary school, it was Helen, a fellow student, who pushed me.  We were rivals in elementary school, friends and colleagues in high school.

In university, it was Lisa, now a palliative care doctor of all things, who encouraged me to switch from Psychology to Neuroscience as an undergrad, and that maybe I should write the MCAT one summer, just for laughs.

In medical school, it was Bertha who took a chance on a woefully unprepared candidate who showed up to his interview high (as a kite!) on cough syrup.  It was also Danielle who joined UWO MEDS 2003 needing to change the world while the rest of us just hoped to pass.  It was my pragmatic roommate Laurie, who helped me to put life’s setbacks into perspective.

It was Charmaine, my first mentor in palliative care, who showed me that palliative care is not a job, its a calling.  It was Janet who encouraged me to give palliative care a second chance following my first experience with burnout.

It was Carol, as executive director for the Hospice of Windsor, who taught me how to lead from behind.  She never treated a single patient in her entire career, but she put dozens of people in a position to succeed, to the benefits of thousands. It is Colleen who has kept our Hospice organization afloat in turbulent times.

I think of Jane, whom I met ever so briefly at the CMA in Vancouver 2016.  She stepped up to make a difference and stepped away with her grace and dignity still intact. And Jody, who exemplifies integrity in times when it is sorely lacking in Canadian politics.

I think of Catherine who is the smartest woman I know, thus giving her only half the credit she deserves.  Secretly I think she enjoys letting us spin our wheels with a problem she had the answer to an hour ago.

I think of Nikki, who is the sister I never had, if you don’t count the seven I already do.  Nikki is gonna murder me for calling her Nikki. Probably on a Friday. (Hey Nik, it’s Sohail here – just a reminder, that Darren calling you Nikki, I would NEVER EVER do that!)

I look at Jacinda who didn’t just flatten the curve, she levelled it like an All-Black in a foul mood.

I look at Hayley, who seems destined to be an even better doctor than she was a hockey superstar. I think of Menon and Kim who inspired me the same as Felix and Marty.

It is all of the nurses, staff, volunteers and caregivers at the bedside of our palliative patients, night and day, without compliant, without fail.

It is my wife who was diagnosed with cancer at 29 and kicked its ass by the time she was 30, got married at 31 (to me, just in case you were wondering) and gave birth to a miracle child at 34.  She comes from a family of ass-kickers.

So, when people talk about the gender pay gap, I wonder, why that is.  Because its 2020, after all.  And much like the evidence for the benefits of palliative care, the avalanche of evidence for the gender pay gap is embarrassing.  The benign neglect to this problem is also similar.

Like all things, you need to start by educating yourself.  Here are some good places to start:

What’s driving the gender pay gap? (CMAJ, 2020)

Here is an article in the Globe and Mail (2019)

You can watch Dr. Audrey Karlinsky’s webinar

And Dr. Leslie Barron’s article

Make sure to keep your eyes out for OMA President Dr. Samantha Hill and Dr. Michelle Cohen’s upcoming article in CMAJ, coming soon.  As well, a Report to Council will be making its way to OMA members soon.  I humbly suggest giving it a read when it does.

Finally, for the men reading this:  This is not about taking something away from you.  It is about giving to them what they have deserved all along.

Respectfully,

Darren Cargill MD

We Need to Learn to Live With COVID-19

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Critical Decisions Looming for Health Care

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

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

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

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

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

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

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

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

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

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

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

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

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

Better Contact Tracing Essential: Requires Improved Public Health Systems

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

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

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

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

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

Piecemeal Structure of Public Health Units (PHUs)

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

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

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

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

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

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

More Wide Spread Testing for COVID19

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

APP for Contact Tracing

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

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

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

The Cruelty of COVID-19

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

Cruel.

This disease is unrelentingly, unwaveringly and inexorably cruel.

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

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

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

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

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

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

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

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

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

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

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

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

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

… you made a difference.

“Gentleness is the antidote for cruelty.”Phaedrus

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

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

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

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

Mornings

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

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

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

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

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

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

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

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

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

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

For more articles like this please go to protecthealthcare.ca

Will Health Care Infrastructure Survive the COVID-19 Pandemic?

This week, it appears that the “surge” of COVID-19 patients entering Ontario hospitals has begun.  In particular the number of patients on a ventilator (essentially life support) has gone from 62 two weeks ago, to around 200 today.  Additionally, the number of people in hospital with COVID-19 related illness has risen to about 740 as of today, with about 261 in Intensive Care.  Ontario has about 2000 ICU beds, so there appears to be some capacity, but if the surge worsens, this may disappear.

Unsurprisingly, the focus of the government has been to prepare the hospitals for inpatient care as best as possible.  This includes ensuring more staff, funding for ventilators, investing in PPE (although it’s unclear how this will arrive) and so forth.

However, while this is all appropriate, it’s important to remember that there are other areas of health care that will need support.  For example, hospitals perform many outpatient services like specialty clinics and diagnostic imaging.  There are also community clinics that provide patient services (your doctors office for example).  All of these clinics have been effectively shuttered due to the physical distancing guidelines, but all of them also keep patients healthy and prevent them for becoming inpatients.

There are likely to be four “waves” to his pandemic.  I would try to explain them all to you, but Dr. Victor Tseung has done a great job illustrating this, and, as they say, a picture is worth a thousand words:

victor

Currently, we are at the beginning of the first wave.  A lot of preparation has been done for this stage, and rightfully so.  I will also say that the Ontario Medical Association (OMA) has done a lot of work to anticipate the fourth wave, by offering virtual check in clinics for our members and by messaging the availability of the services we offer for help with burnout and stress.  I believe it was Dr. Mamta Gautam who coined the phrase “pre-TSD”, which is what many physicians are experiencing right now.  Better to address this head on now, then wait for it to turn into something worse.

Quite frankly I worry, that not enough attention is being paid to waves 2 and 3.  Canada’s health care system was already overburdened to begin with.  We were (sadly) famous for having ridiculously long wait times.  Along with those increased wait times comes increased morbidity.  Morbidity refers to the burden of multiple health conditions over time.  Supposing, you have terrible arthritis in your knee.  You don’t walk because of the pain.  Over time you become more sedentary and develop a blood clot in your legs, that then breaks off and goes to your lungs.  All of which could have been avoided if you had your surgery in a timely manner.  That’s morbidity.

See many (if not most) of the medical services provided to patients who will suffer in wave 2 and 3 are provided by outpatient physicians.  These physicians work at clinics in hospital, or their own offices or at what are called Independent Health Facilities (IHFs).  IHFs are non-hospital clinics with equipment (e.g.  X-ray, Ultrasound, Labs,  heart imaging).  They are provide the kind of care that reduces the load off our hospitals in difficult times.  By allowing doctors to diagnose and treat chronic illnesses sooner, they prevent morbidity.  Their work has never been so important.

What’s a good example of a wave 2 patient?  Supposing a patient has glaucoma, a build up of pressure in the eye.  Untreated, this will lead to blindness.  Many patients require laser surgery to relieve the pressure, but eye surgery has been stopped due to the current pandemic.  Eventually this will catch up to people.

Wave 3 patient?  Someone who has heart disease, but isn’t able to get their Echocardiogram (a type of heart ultrasound) to assess their condition.  Waiting a few weeks is probably ok, but at some point, their heart is likely to deteriorate further, and they will wind up in hospital, which is the last place you want to send someone these days.

What’s that you say?  Why can’t health care infrastructure just start up again in a few weeks?  Here’s where the business side of medicine, which no one likes to talk about, comes in.  Many clinics and IHFs are run on a tight budget after years of cut backs by previous governments.  So what happens is a patient comes in for a test, OHIP pays for the test, and the clinics use that money to pay for nurses, technicians, rent and leases on some of the equipment.  Some of the equipment can cost millions of dollars.

These are generally small businesses.  The simple reality is that without people coming in (which they aren’t right now as non-essential treatments have stopped), there is no money coming in, and so the overheads don’t get paid.  Unlike large companies like Apple or Google, these businesses don’t have much cash in reserve as the overhead is so high, so they will go under.  I know of many clinics that have laid off staff right now, in order to try and get an extra months rent and lease paid.

Of course, this is the same plight that faces all small businesses across Canada.  Certainly, it would be remiss of me not to point out that just about everybody is feeling economic pain right now.  Many people have been laid off, gone on EI and are suffering.

The thing is, health care is an essential service.  Without them, all of the ongoing outpatient care and preventative care I was talking about won’t get done.  If that happens, patients will get sicker and wind up in hospital.  Or worse.

These are difficult times for all of us.  But if we are to get through the COVID-19 crisis, not only do we need to take a short term view and address the immediate surge, but a much longer view must also be taken.  This means supporting health care infrastructure.  The well being of our patients depends on it.

Canadian Physician Growth Lagging Behind Demand, Other Western Nations

Note:  The following was initially published in the University of Toronto Medical Journal in Mid-March and is being reproduced here.  My thanks to the OMA staff for helping with the research.  As we enter the “surge” phase of the COVID-19 Pandemic, I pray that that our already short staffed physicians will come through this ok.

I have been a family physician for over a quarter century, and chose to practice in the small community of Stayner, Ontario. Working in a rural community has given me a closer connection to my patients, and a stronger understanding of the challenges in Ontario’s current health care model and how it could be improved. In the end, everything doctors do is in aid of better patient care and better patient outcomes.

What I’ve seen and experienced shows me that we need to change the landscape of medical care. It’s one of the reasons I became involved in medical politics. It’s something I continue to focus on as President of the Ontario Medical Association.

First and Foremost, We Need More Physicians in Canada

Our population is aging. Our patients are becoming more complex. The rate of growth of Canadian physicians to population needs to keep pace. How many more doctors do we need? Well, it really depends.

There is no straight-line comparison between these factors and the number of physicians required. I would suggest it also depends on the distribution and prevalence of specialties and sub-specialties, the age of physicians, their models of practice, and other resources (particularly allied health care professionals to assist physician led teams) available within the health care system. There are many nuances.

Although there is no magic target number to reach for, we need to look at making a significant investment into training and hiring physicians in Canada in order to fully meet the health care demands of our patients.

To those who say we cannot afford it, I pose an only somewhat rhetorical question: How much money does it cost right now to care for a high needs diabetic with COPD and heart disease who goes to the Emergency Room regularly because he or she doesn’t have a doctor?

Growth in physician ratios not keeping pace with need

When the Canadian Institute for Health Information (CIHI) reported that in 2018, Ontario had 2.34 physicians per 1,000 people – up from 2.26 in 2017 – this was heralded by some as a dramatic increase.1 Although I was very pleased to see growth in physician numbers – because I believe this is necessary to improve patient care – I would have been more bullish had I not noted four things that make this statistic somewhat less rosy.

  1. Ontario Ranks Seventh of Ten Provinces in Physician-Population Rates

Even with a 3.5% percent growth in physicians to population over 2017, Ontario still ranks seventh out of ten provinces. Ontario was ahead of only PEI (1.97), Saskatchewan (2.05) and Manitoba (2.25). Ontario is also below Canada’s rate overall of 2.41 physicians per 1,000 population.1

  1. Recent Growth is Making Up for Past Stagnation

The growth in Ontario’s physician-to-patient ratio is a relatively recent phenomenon.

A review of CIHI data for the period 2001 to 2018 shows that the number of Ontario physicians has grown an average annually of 1.6% more than the growth in the province’s population.

However, the rate of growth during the period 2001-2008 was essentially flat, with the ratio stuck at about 1.8 physicians per 1,000 people for eight years. Therefore, some of the recent increase in annual growth is actually catching up to meet demand from the past.

Additionally, whether or not the rate of growth of physicians meets or exceeds the population growth is not the whole story. It’s simply not enough to say that the population has grown by, say, one percent so we need one percent more doctors, as there are many other determinants of the need for physician services, such as aging and increasing clinical complexity and multimorbidity.

  1. Ontario Sees an Annual 3.6% Growth in Physician Services

Ontario experiences a 3.6% annual average growth in services provided to Ontario patients, representing the cumulative impact of population growth, aging, patient complexity, advances and availability of technology, and other factors.2

Recent analysis carried out by the Ontario Medical Association’s Economic, Policy and Research department demonstrates that prevalence of multiple chronic conditions in Ontario has grown from 2008 to 2017.

This has caused an increase in something called patient resource intensity. As of 2017, the number of patients with at least one out of a baseline list of 84 chronic conditions was estimated to be 9.8 million, an increase of 11.0% from 2008. Multimorbidity also rose. The number of patients with two or more chronic conditions increased by 12.2%, while those with three or more increased by 13.5%.

This means that Ontario patients are becoming more complex, and thus require more time, resources and physician manpower to look after. Given that the majority of health spending can be attributed to multimorbidity, these findings have major implications for population health management and health care spending.

Although this analysis is based on Ontario patients, it is hard to imagine that the same demand does not exist, in whole or in part, in other jurisdictions across the country.

Advances in technology to both diagnose and treat have also increased the ability of physicians to provide care to their patients, which puts further demand on physician resources.

All of this illustrates that patient demand for services is growing significantly, and we need more doctors each year to meet it. The ones we have will have to work ever harder. According to the Canadian Medical Association, doctors already work an average of 52 hours a week, and in many cases work more hours being “on-call” on top of that. It is not sustainable or even tenable to ask doctors to work more.

  1. Canadian Physician Rates Are Low Compared with Other Western Countries

In contrast with other comparable countries, Canada’s physician-to-population ratio is low. While there are many factors determining the optimal number of physicians, it is hard to argue that Canada has too many physicians relative to its peers.

1 for article2 for article

What does this all mean? The reality is that Canada often gets lambasted for poor health care metrics in the press (e.g. wait times). However, it is clearly impossible to meet some of the noble goals when there simply aren’t enough physicians to do the work. We can invest in programs like public health, telemedicine, pharmacare and so on. These are all good and noble causes that have been clearly shown to benefit populations of patients. But until we recognize that our main problem is a shortage of physicians and that the growth needs to accelerate even more, our overall health metrics will not achieve those of the countries we aspire to.

COVID-19: The New Normal

This article first appeared in healthing.ca, and is reproduced here for those of you who don’t go to that website.

I was on call this past weekend for my Hospital (Collingwood General and Marine).  It’s considered a “Level I” hospital which (in my opinion) expertly provides care for common health conditions to the 75,000 residents in its catchment area.

Driving to Collingwood on Saturday (I live just outside of town) was, well, jarring.  You see, it was the second Saturday of March Break.  We are near Blue Mountain, Ontario’s largest ski hill.  This is supposed to be our busy season.  My patients rely on tourism to make the local economy go. But Blue Mountain is closed because ofCOVID-19. Other businesses were closed as well. And the town was eerily empty.

Empty Town

As I drive by the hospital, I see “the tent.”  That’s the place where all people who enter the hospital must go first to be screened for potential COVID-19.  The disease is now in what’s known as the “community spread” phase.  People who haven’t travelled may have got it and are giving it to others.  Essentially, anyone who has signs and symptoms of a cold or the flu, is presumed to have COVID-19.

Covid Tent

As I walk into the tent to get screened, I marvel at the courage and integrity of not just the doctors and nurses who work there, but at the volunteers staffing the station.  These volunteers must all wear Personal Protective Equipment, and they are constantly wiping down the surfaces.  They still volunteer, even though they are potentially exposing themselves to a serious illness – even after it was announced that our hospital had a patient with COVID-19.  I am truly inspired by their profound commitment to the community that they serve.

As I contemplate all of this, I realize I’ve gone the wrong way. I’m currently averaging over 125 new emails a day, the majority of which deal with COVID-19 and I’ve somehow missed the one that informs me that staff need to go through a separate, dedicated entrance.  The email said I have to show my badge.  (It’s a small hospital, we all know each other, and I don’t think I’ve shown my badge to anyone in 25 years).

A quick walk around the back to the screening site.  It’s necessary.  It’s important.  I agree with it being done.  But it’s still weird to be screened at a place you’ve worked at for so long.

Screening Door

I walk by housekeeping and wave hello to some of the unsung heroes – the cleaners -who were having a meeting.  Once a patient with any transmissible disease (whether COVID-19, or MRSA, or C.difficile or other) is discharged from hospital,  it falls to the cleaners to follow rigorous and thorough cleaning protocols, to ensure that the next person in that room doesn’t get the disease.  Truly unsung heroes they are, who never get the credit they deserve.  While, – all I can offer them is a public thank you, I hope they know it’s heartfelt.

My call group has 12 inpatients this weekend.  It’s less than usual.  The nurses, as always, know the patients really well and fill me in on concerns they have.  It’s the usual mix of medical and surgical conditions.  My initial thought is to grumble once again about the fact that talking to patients takes less time than documenting on our click happy Electronic Medical Records system.  But I realized that the fact that this one thing hasn’t changed actually provided me with a sense of normalcy, for which I’m grateful.

I can sense that the staff are concerned about the circumstances. Yet despite this all of the nurses, ward clerks, cleaners, doctors and many others, are doing their jobs at peak efficiency.  Kindness and consideration for patients is evident in all of them.

Next stop, a shift at the after-hours clinic.  The clinic has changed drastically in the past week.

Front Door Walk inEntry to Walk In

A volunteer meets patients at the front of the building and explains that they have to call a number and wait in the car.  When it’s their turn, I call them, and see if I can handle the problem over the phone.  If they have symptoms of a cold or the flu, they are not allowed in the building as we don’t have a protected room or personal protective equipment.  Patients with mild symptoms are given advice to get better at home.  Those with more serious symptoms are sent to the COVID-19 tent at the hospital.  The family doctors in our area have a good working relationship with the hospital, and we are able to work together and co-ordinate care in times like this.  I wish every part of Ontario had this.

I’m able to treat about 70% of the patients this weekend by telephone.  It’s not ideal, but it improves Social Distancing, which is now an urgent requirement to help flatten the curve and slow the spread of COVID-19.

The next day, is essentially lather (for twenty seconds people!), rinse and repeat.

So, what thoughts do I have about the new normal?

It strikes me that this is going to be life for the next several weeks at a minimum.

I’m worried about many people on marginal incomes, who will be feeling economic pain in the coming weeks.

I’m worried that Social Distancing, which is really physical distancing, will lead to social isolation for many members of the community, and we will see an increase in mental illness over the next few months.

I’m on edge, hoping that we don’t see the same disaster as Italy is going through, and I know my colleagues are as well.

Yet with all that, I also see a lot of hope.  From across our community, volunteers are staffing the registration desks at the hospital and the after-hours clinic to help out.  The nurses and doctors continue to maintain an incredible degree of professionalism and kindness towards the patients, even though their lives could be at risk.  Physicians are donating unused swabs to the hospital so they can screen more people. I’ve had numerous offers from physicians to volunteer in the assessment centres.

I don’t know how long this situation will last.  I don’t know what history will say about us.  But what I will always remember is that despite the fear, anxiety, and stress, it was the kindness, generosity and courage of the people that shone through.

Conscience Rights Matter

As my loyal readers (both of them) know, I happen to be a Trekkie.  Permit me to digress a bit, and reflect on one of Captain Jean Luc Picard’s best speeches (Nerd Alert: from the Next Generation episode “The Drumhead”):

“With the first link, the chain is formed.  The first speech censured, the first thought forbidden, the first freedom denied, chains us all irrevocably.” 

 Picard goes on to point out that these words served as wisdom and warning that the first time anyone’s freedoms are trodden upon, we are all damaged.

 I think of his speech a lot with debate on Conscience Rights for health care workers being played out in the public.  In particular, I think of the decision by the divisional court of Ontario, and then the Ontario Court of Appeal to deny physicians conscience rights.  The courts claimed they struck a “reasonable balance”.  But they also went on to expressly state in their ruling that the “referral requirement does infringe on doctors’ religious freedoms.”  Make no mistake about this, rights and freedoms of certain individuals are being violated by this ruling.

 In the 1980s, the hot button issue driving the desire for Conscience Rights was Abortion. In 2020, the main issue is Medical Assistance in Dying (MAID).  Many physicians’ groups have expressed concern about being forced to make a referral for this service, in violation of their morals and ethics.  This concern has been expressed not just by physicians of faith, but by secular groups like the Canadian Society of Palliative Care Physicians.

 Let me be clear about this: Neither myself, nor the Ontario Medical Association will support any physician who actively impedes or prevents a patient from accessing any legal medical service (including MAID).  Period.  Full Stop.  This includes statements like “If you want MAID, I will no longer be your doctor.”  That’s just not on.

 However, for physicians who feel that actively referring a patient for such a service violates their principles, surely there can be a work around.  Turns out, that’s exactly the case in Ontario.  If a patient wants MAID, they simply have to contact the MAID co-ordination service and the service will ensure the patient gets the appropriate assessments.  Surely handing a patient the contact information (which is not a referral) and leaving it up to the patient to contact the service (which is the patient’s right) is sufficient.  Physicians’ conscience rights are protected, and no patient is denied access to a service they want.

 Some argue that there will be cases where this is insufficient for various reasons.  I disagree.  In order to access MAID, you have to be mentally competent.  If you’re not competent enough to dial a phone number and ask for this service, you’re not going to qualify anyway.  Forcing a physician to do a referral (which involves putting your signature indicating you support the request on a form, setting up the appointment, informing the patient of said appointment and more) in violation of their conscience, isn’t going to alter in any way whether the patient is an appropriate candidate for MAID.

 For me however, there is a bigger picture that many people may be missing.  We live in an era where technological advances are rapidly occurring.  These advances are not just related to computers, and possible interfaces with humans – think ports at the back of your skull to download information directly into your brain – and no, that’s not just science fiction, Elon Musk (yikes!) and Facebook (double yikes!!) are exploring this today.  However, the more stunning advances, and I believe the ones with the greatest potential for ethical dilemmas, are the ones in genetics.

 Look what’s already happening thanks to gene editing by CRISPR.  A scientist in China has edited babies genes. Designer babies (hair, eye colour on order, muscle and IQ per your specifications) are so within the realm of possibility that the ethics are already being debated.  Rapidly progressing work is being done to identify the genes (it’s not just one gene, but likely a cluster of several) that link to autism, Asperger’s and, yes even sexual orientation.

 To those physicians who are opposed to legal protection for Conscience Rights, let me ask you this.  What would you do if a patient asked you for a referral to have only a blue eyed, blonde haired baby? 

 Becomes a moral quagmire doesn’t it?

 Another Star Trek Captain, James T. Kirk, once said (Nerd Alert:  The Original Series Episode: “A Private Little War”):

 “There came a time when our knowledge grew faster than our wisdom, and we almost destroyed ourselves.”

 This is why Conscience Rights protection is so essential in society.  With the explosion of knowledge that is going to continue over the next few decades, it is essential that we handle these advances in fair, ethical, and yes, moral manner.  In order to do that, we must allow health care workers the same freedoms as everyone else in society on matters of conscience. 

 The first link in the chain has been formed.  It’s time to break that link with legislation that protects everyone’s fundamental freedoms.