Health System Reform Must Include Physicians

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The following was written by Dr. Jim Wright (pictured above) and Dr. Adalsteinn Brown. I found the blog very thought provoking.  Reproduced at their request and with permission.  Opinions, are theirs.

Ontario has embarked on a bold experiment to transform care with a large focus on Ontario Health Teams or OHTs. At maturity, OHTs will be responsible for the full continuum of care within a community. As the Premier’s Council’s latest report suggests, OHTs should be able to provide an integrated experience for patients, an experience that takes advantage of the latest digital technologies to deliver care where and when patients need it, and that relentlessly improves against the quadruple aim goals of better population health, better cost, better patient experience and better provider experience.

This is a laudable vision and one that is long overdue in Ontario. Several health systems have already begun experimentation, implementation and even evaluation of these sorts of integrated models of care. And while no model of care is a panacea, there are some limited but encouraging signs from these other systems. The history of health system reform, however, in Ontario is one of largely excluding physicians from leadership. So, an important question for physicians in Ontario is how to respond to the OHT reforms. In this blog we consider this question and make some suggestions around the hows and whys of physician engagement in these reforms.

First off, it is important to state the obvious; Health system reform must include physicians. Physicians remain responsible, with their patients, for most decisions around care. It is hard to expect a system of care to change unless that reform engages and works with the physicians. Moreover, the importance of physician (and all clinicians) in reform is clear. One of us has argued previously that clinician engagement and leadership is one of the three must-haves for any health system undergoing reform and is more important than the typical Canadian paths to health system reform like regionalization, electronic medical record implementation, or compensation structures.

Perhaps as importantly, early evidence from the US and the Accountable Care Organization (ACO) experiment where communities of providers come together to take care of defined populations suggests physician leadership is key  to success. Those ACOs that had physician leadership (and particularly primary care leadership) tended to do better. A recent supplement to the New England Journal of Medicine focussed on how to build strong physician leadership in ACO type models.

The ACO experience is important because it is based on a model of risk or gain-sharing where ACOs become responsible for the care and the costs of that care. As care improves, prevention increases and patients are able to stay at home or in the community, ACOs share in these savings. In some models, they can also share in the losses. How should physicians engage with these sorts of models? With this question, it is important to parse carefully the evidence and the OHT model. The first conclusion is that individual physicians should not face risk or gain-sharing on their own patient populations. Although OHTs will manage hundreds of thousands of patients, individual practices will not be large enough to manage risk. One very ill patient could change the cost profile of an individual physician’s practice and we do not want to encourage reforms where physicians are punished for taking on the sickest and most vulnerable patients. Experience with other reform efforts suggests that these sorts of approaches can leave patients without necessary care.

If not risk or gain-sharing on their own patient populations, then should physicians face a pay-for-performance type system where they are encouraged to provide certain types of care or discouraged from other types of care? Again, the conclusion is no. Repeated Cochrane Collaboration reviews have showed a lack of evidence to support pay-for-performance. Although a number of Canadian provinces have implemented pay-for-performance schemes, these have tended to buy small amounts of change in process without impacting outcomes or larger goals like sustainability or equity. In addition, P4P shifts the activity from improving integration to one of compensation. Finally, P4P also inevitably focuses on the metrics rather than the goals of the reforms. Instead of focusing on improvements in the system, P4P often leads to arguing against the metrics.

So, if physicians should be engaged and should be part of OHTs, but should not face risk-sharing or pay-for-performance at an individual level, then how should they participate in OHTs? It is important to remember that OHTs are a new form of organization in Canadian healthcare. Physicians can and should be part of and help lead these organizations. But any incentives they face and any thoughts about risk and gain-sharing should reflect the success of the organization, not of an individual within that organization.

The alternative to gain/risk sharing is to view the improvement in the health of populations, improved quality of care and enhanced integration are incentive enough to encourage doctors to participate in OHTs and change their practice. Doctors want to do the right thing for their patients. Furthermore, enhanced integration will relieve the administrative burden for doctors, should improve their productivity, and most importantly, allow them to spend more time directly caring for patients. Any financial gains of OHTs instead of accruing to doctors could instead be invested in patient care, such as enhanced IT systems or patient navigators and spread out over necessary improvements (and increases in care).

This means that performance measurement and reporting is key. Performance indicators of what we want to achieve in this reform, grounded in the quadruple aim, will be critical. This will also help physicians see and stay focused on improvement. It also means that stronger financial management is key. Without such management, individual OHTs will not be able to prioritize investments in better care. Finally, it re-enforces the importance of physician engagement and leadership. Without it, we risk losing the connection between better system management (and improvement) and the decisions made at the front lines of care.

Although not all will agree, for doctors, health care reform should be all about improved care and integration for all and not about financial gain (and loss) for some.

James Wright is Chief, Economics, Policy & Research at the Ontario Medical Association

Adalsteinn Brown is Dean and Professor at the Dalla Lana School of Public Health, University of Toronto.

Ontario Health Teams A Good Start For System Transformation

The Ontario health care system is in distress.  Frontline health care workers like myself know this.  Many of the rules that we are forced to abide by are archaic and make no sense.  Outdated fax technology only flourishes in health care.  Hospitals are bursting at the seams.  Home care is proving woefully inadequate.  Sadly, patients are suffering from the consequences.  This is what 15 years of neglect and lack of foresight by the previous Ontario Liberal government has caused.

To fix the situation, the new Conservative government of Premier Doug Ford is proposing what has been called the most massive transformation of health care since Medicare. The first step is to form an agency– called Ontario Health – that will merge up to 20 different agencies into one.  Long-time fans of mine (all three of them) will know this is music to my ears.  It was step three in the seven-point plan I urged then-Premier Wynne to follow to fix health care back in 2017.  I can’t help but be pleased this is finally happening – and certainly expect a significant reduction in Ontario’s bloated bureaucracy as a result.

The second step is to form a number of “Ontario Health Teams”(OHTs).  The goal of these teams is to provide Integrated Care Delivery Systems (ICDS).  There’s a lot of bureaucratic verbiage in the documents released to date, but essentially the goal is to ensure that different health care providers (doctors/home care/hospitals, etc.) work seamlessly to deliver care to patients, as they move through the health care system.  I know, it sounds incredibly basic, and should be straightforward, but unfortunately, it just doesn’t happen as well as it should right now

Can OHTs work?  As always, the devil is in the details.  The first thing that is needed is the political will to transform the health care system.  This is clearly evident.  Health Minister Christine Elliott has been widely lauded as a very capable minister and truly has the ability to provide the political will necessary.  Dr. Reuben Devlin (the Chair of the Premier’s Council on Ending Hallway Medicine) is a strong leader as well.  Thankfully, the person who will have to do a lot of the bureaucratic heavy lifting is new Deputy Minister Helen Angus.  I’ve written about her before, and she certainly appears to be a very strong deputy minister.  I think she’ll do very well.

The next step is to ensure that similar models across the world are studied, and only the successful ones copied.  You see, the OHTs appear to be the Ontario version of something called Accountable Care Organizations (ACOs – I know, you have acronym overload by now).  The goal of ACOs is to provide an amount of funding to a geographic region, and to have all of the health care delivered to patients in that area paid for by that funding.  The OHTs however, appear to be taking a more cautious, pragmatic approach, and are only going to provide funding for outpatient services, and not include physicians’ services. They may evolve in the future, and it’s a smart move on the government’s part not to move too quickly.

Now, the reality is that only some ACOs worldwide actually meet the goals of simultaneously improving health care while reducing health care costs.  So it’s incumbent upon OHTs to reflect those effective models, and not the ones that have failed.  What do the successful models have in common?

First, it is essential to have strong physician leadershipin these models.  For too long, Ontario’s physicians have been blocked from providing advice to the government.  Physicians work on the front lines of health care delivery, and see the effects of bad policy every single day.  They have many ideas on how to transform health care for the better.  The previous Liberal government only viewed front line health care workers as eye candy for photo ops and nothing more. Thankfully, this seems to be changing, and it was refreshing to have Premier Ford’s Senior Advisor Greg Harrington come to visit us at the Ontario Medical Association head office last week (I can’t recall anyone from Kathleen Wynne’s office visiting us).  Governments co-operating with physicians can only help patient care.

Secondly, the mess that is Ontario’s IT infrastructure needs to get cleaned up quickly. You see in 2019, for seamless care to be provided to patients, hospitals need to talk quickly, securely and electronically with home care providers.  Doctors need to talk to pharmacies.  Nursing homes need to get doctors quickly.  In short, the relevant data has to follow the patient.  Projects like the one I was proud to spearhead in Georgian Bay have proven that we can save money and provide better health care at the same time.

These are challenging times in health care, but there is also a great opportunity.  By properly instituting OHTs, Ontario has a chance to finally start reversing its poor record of the past 15 years.  Done properly, this reform of health care could also be a lasting legacy for Premier Ford.

Let’s get it done right.

A Personal Journey Through Public and Private Health Care

Disclaimer:  The following blog was written by Dr. Darren Cargill (pictured below).  He asked that I put it up for him.  Dr. Cargill is a palliative care physician from Windsor, Ontario.  Opinions are his and his alone, and do not necessarily reflect my opinions, or those of the Ontario Medical Association.

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Recently, a series of articles in the Toronto Star claim that Ontario Premier Doug Ford is looking at “private” options to end hallway medicine.  This was, of course, immediately denied by Health Minister Christine Elliot who stated her government’s ongoing support for public health care.

To support this narrative, the Ontario NDP brought forward a leaked piece of draft legislation called the “Health Systems Efficiency Act”. This draft suggests that all 14 Local Health Integration Networks (LHINs) and many other agencies (Health Quality Ontario, eHealth, etc.) are to be rolled into one big Agency.  NDP Leader Andrea Horwath claims that this draft legislation is a signal that private health care is the real agenda for the Ford government.  Interesting times for health care in Ontario.

In Andre Picard’s book “Matters of Life and Death,” he eloquently outlines the history of Medicare in Canada, warts and all.  I think we can all agree with his comment “Canadians want care that is appropriate, timely, accessible, safe and affordable, from birth to death.”

So here is our story. In 2007, my wife was diagnosed with cancer. She received excellent care here in Windsor as well as at Western in London as part of her journey.  I can honestly say, that she would not be here today if not for that excellent care. I am indebted to our system for saving her.

Getting cancer at 29 is frightening.  When we wanted a second opinion to confirm the diagnosis and ensure that we were receiving the best possible care, we booked an appointment at Karmanos Cancer Centre in Detroit.  A second opinion in Ontario would have taken months. We got our appointment within days across the border. They confirmed that Windsor was giving us fantastic care.

At one point during her treatment, she needed an MRI.  The wait was many months in Ontario.  At first, she was ok to wait but as the days passed, the wait took its toll.  Eventually, we decided to go to Detroit and have the MRI done, with only a few days wait and near instantaneous access to the results.

When we needed help conceiving following chemotherapy, this too was not covered by our public system and we paid out of pocket for that.  We required help from physicians in both Windsor and Detroit. Today we have a son.  And he has a mother.

Neither system alone gave us what we needed. It was both.

We already have private health care in Canada.  Doctors’ offices are privately run businesses that rely on single-payer public funding to operate. We also have private care when we pay out of pocket for drugs, physiotherapy, psychotherapy, fertility treatments, and dental care.  Canadians already spend money out of pocket for health care so the fears around a “two-tiered” system are odd, to say the least. Two-tiered refers to the argument about equity, not public/private, in my humble opinion.

Many will claim I am a physician and had “the means” to avail myself of private care.  But for the record, I was less than 2 years into my career and still had over two hundred thousand dollars in debt from tuition gathering interest every day.  We had to ask family for loans to support us.

For me, the price was worth it.  I would have preferred to have all of our care provided in Canada, but the public system simply could not give us everything we needed.  I believe it was providence that we ended up in Windsor, a short drive away from a world class cancer centre and fertility experts in Detroit.  Ontario gave us most of what we needed and prevented catastrophic financial consequences but privately delivered care in Detroit helped to fill in the gaps.

Why couldn’t I have those options in Canada?

To be clear, I am not suggesting we adopt a US style for-profit system and I am not suggesting we abandon our public system. What I am suggesting is that we have a mature conversation about our system, it’s limitations and whether there is a way to supplement or augment our “good not great” publicly funded, single payer system with private options that could enhance the care we deliver. Can we make our system better through private innovation and efficiencies while preserving all the best parts of public Medicare?

I am asking for a conversation.

As a palliative care physician, I won’t benefit from privatization.  End of life care and symptom management for patients with life-limiting illness will remain publicly funded.  But end of life care does give us a great example of what a good conversation could look like.

In 2015 the Supreme Court of Canada’s Carter decision came down and we were required, as a nation, to address the issue of Medical Assistance In Dying (MAID). Previously, MAID was taboo and “verboten.”  We could not raise it with our patients or even discuss it. But a funny thing happened. Once this prohibition was raised, it got easier to discuss death and dying. Whether or not you support MAID or not, one thing is indisputable.  The conversation has been elevated.

In his book, Picard states “we talk endlessly about sustainability of Medicare but have no idea what we want to sustain.  Our Medicare model is a relic, frozen in time. Tommy Douglas’s role in shaping publicly funded health care is celebrated, mythologized even.  But we conveniently ignore that Medicare was designed to meet the needs of 1950s Canada.”

All on the first page of his chapter on Medicare.I couldn’t agree more.  And while we are at it, let’s stop tilting at wind mills.

I do not pretend to have all the answers.  I just know we need a mature conversation about public AND private health care.  Let’s not shut down the conversation out of fear-mongering and ignorance. To paraphrase former CPSO president David Rouselle: “let’s not repeat the same sterile conservations again.”

How to “Axe the Fax” in Health Care

Recently, Globe and Mail Health Columnist Andre Picard wondered why fax machines are still the norm in health care.  Electronic communication is faster and more efficient than faxing.  In the past, it was thought that faxing was at least more secure.  However, with the emergence of “faxploit”, and reports showing how missed results are worse, it’s clear that secure electronic communication is safer.  Britain has moved to “axe the fax”in health care, acknowledging that using fax machines is farcical.

So why are faxes used so often in health care?  I can’t speak for other provinces (although the answer is likely similar) but in Ontario, it’s because the IT infrastructure for health care was so poorly thought out by the previous Liberal government that there really is no choice.  There is a mis-mash of different software for different health care providers, none of which interacts with each other.

Physicians in Ontario currently are able to purchase one of twelve Electronic Medical Record (EMR) services. NONE of these services is actually able to communicate with each other electronically.  Going from one doctor to another, means that your records are not interchangeable.

Hospitals in Ontario have the choice of even more products, though generally pick one of the three most physician unfriendly versions.  The Home Care system uses a Province wide system, but can’t interface with hospitals and physicians.  Then there’s Public Health, multiple allied health care agencies, nursing homes and so on.

The result is a byzantine system with no easy co-ordination and absolutely no interchangeability.  Hence, I fax referrals to Home Care, specialists fax me with their consult notes, and nursing homes fax me three month drug reviews.

The most commonly suggested solution for this problem is to develop something called a Provincial Electronic Health Record (EHR).  The idea is to have every health care provider get rid of whatever software they are using now, and use one Province wide system only.  The system would be cloud based, and allow you only to access the information that you have privileges for.  For example, family doctors could see the whole chart, but a pharmacist could only access the medication record (and some relevant lab work), a personal support worker would only be able to access notes they had written and so on.

In an ideal world, this makes the most sense of course. However, proponents of this solution fail to recognize that this will be exceptionally costly.  There are the initial costs of development of such software. But there will be additional hidden costs to such a solution.  EVERY health care provider in the province will have to get re-trained on this new software.  We’re talking all 30,000 doctors, 100,000 nurses, goodness knows how many PSWs, Pharmacists, Pharmacy Technicians, radiology technicians, clerical staff etc.

Unfortunately, the reality is also that when people go from one system to another, mistakes are going to be made and there will be a number of errors.  These errors will also have a cost to them.

But what can be done then?  Clearly the current system of archaic faxing is unacceptable. Turns out there is a solution that is relatively easy, relatively in-expensive and has already been piloted with great success in my neck of the woods (Georgian Bay, Ontario).  The government should mandate that all health care software providers must have an Application Programming Interface (API) that meets a rigid province wide standard, by the end of this year.

As I’ve written about before, when I was Chair of the Georgian Bay Family Health Team, my colleague Dr. James Lane piloted a project that allowed pharmacies limited access to our Electronic Records and allowed secure communication between pharmacists and physicians. There were numerous efficiencies and safety benefits, including an unexpected 90% reduction in drug diversion (selling/stealing of opiod prescriptions).

In 2014 we used an API to allow us to communicate securely with our nursing homes.  The result was an over 50% reduction in admissions to our local hospital from nursing homes.  The cost of the API was about $35,000 a year. The funding ended in 2018 and for whatever reason our LHIN has chosen not to continue funding it – and of course hospitalization rates are going up again.

Having a provincial standard for an API can be done easily (there are multiple existing standards out there).  Forcing the software providers to add this to their software will take a little intestinal fortitude, but I suspect the current government has that.  By doing so, it means that a physician, can continue to use whatever EMR he has, but transfer relevant data electronically to home care, public health, hospitals and so on.  It will mean that the agencies can communicate directly and quickly with each other on the patient’s chart, without the mess that was caused by faxing. Our system was actually compatible with smart phones, so home care nurses could message a physician’s office right from the patient’s home.  And, it will be far less expensive than developing a brand new system.

The time to mandate a Provincial API Standard probably came 8 years ago.  Hopefully 2019 will be the year it happens.

Specialists in Ontario are Being Played…

Looking through my in box, I see:

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

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

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

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

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

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

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

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

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

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

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

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

A Few Random Thoughts

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

Changes at the Ministry of Health (MOH)

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

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

Changes at the Canadian Medical Association (CMA)

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

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

More Thoughts on the Strike in Thunder Bay

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

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

Ontario Medical Association (OMA) Becoming More Outspoken

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

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

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

 

“Smokey” Thomas Fails His Members

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

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

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

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

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

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

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

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

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

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

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

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