A Physician Speaks Out About Long Term Care and COVID19

Dr. Silvy Mathew

The following blog was written by Dr. Silvy Mathew, who is by far one of the smartest people I know, and a dedicated and compassionate family physician to boot. It originally appeared as a Twitter Thread after she chipped in to lend a hand at a Long Term Care facility in crisis. It is being reproduced here with permission.

Tonight is 3rd night of no sleep since I went into a Long Term Care home (nursing home) in Ontario with over a hundred COVID19 positive residents, and almost no staff. So far, my other nursing homes have avoided outbreaks, but what I witnessed yesterday is needing words I don’t have. My brain can’t rest, and I think I’m in shock.

I’m not even tearful. I’m not afraid for myself (although yes the conditions were not good and Christmas with elderly parents is cancelled for sure now). I am just … hyper-vigilant.

I woke up after a couple hrs of sleep, having “dreamt” of another catastrophe. What I think my brain is ruminating on is how many levels have gone wrong here. This isn’t an individual’s fault, this is just so damn systemic. And with the right resources and people in charge, given some power to leverage things, we could probably stop some deaths.

But the system doesn’t allow for that. And asking individuals to do more…and more…and more… While we are all trying to maintain their other responsibilities… This is why things are crashing and burning now. It is traumatizing to say the least.

The worst is that only those of us who share these experiences and work in the same environment, can empathize. Empathy is lacking as a whole in our society, but even among colleagues because it feels (and is) like a war environment. And that itself is shocking nine months in.

At this point, it’s too late to stop events or focus on who’s responsible. Mitigation is key, but requires leadership, ground knowledge, and support.

I can say that the “boots on the ground” were women. All colours, various ages. And yes, a few men. Physicians, nurses, PSWs. Those whose pay is less were more likely to be BIPOC and female. The ones without sleep or breaks? Female.

I wish I took the contact of the RPN I worked with. She was one day new and a superstar. A hero. Maybe I’ll cry at some point but right now, I wish I could sleep.

Does Bill C-7 Make Assisted Death the Path of Least Resistance?

The following blog was co-written with me by Dr. Leonie Herx, Division Chair and Associate Professor of Medicine at Queen’s University and Past- President of the Canadian Society of Palliative Care Physicians and Dr. Ramona Coelho, a family physician who provides care to a large number of marginalized patients. A version of this opinion piece initially ran in the London Free Press on Saturday December 5, 2020.

As the COVID-19 pandemic dominates the political agenda and strains the country’s health-care systems, the federal Liberals are intent on passing Bill C-7, which proposes to expand medical assistance in dying (MAiD) to those who are not dying. Proponents of the bill state that it allows choice and dignity for those with chronic illness.  However, the bill fails to provide them with the dignity and humanity of requiring them to have good care or access to supports.

As physicians, we witness the struggles that confront our patients and their loved ones every day. Those living on the margins and with disabilities face significant barriers to care though systemic discrimination (ableism) that can make it harder to live a healthy, fulfilling life in community. As doctors we should be instilling hope, supporting resilience and using our expertise to find creative solutions to address health and wellbeing. Instead, we now will be required to suggest assisted suicide as an option.

Spring Hawes, a lady who has a spinal cord injury for 15 years publicly stated, 

“As disabled people, we are conditioned to view ourselves as burdensome. We are taught to apologize for our existence, and to be grateful for the tolerance of those around us. We are often shown that our lives are worth less than nondisabled lives. Our lives and our survival depend on our agreeableness.” 

A choice to die isn’t a free choice when life depends on good behaviours and compliance to societal norms. Sadly, the medical community can be complicit in this messaging.

Gabrielle Peters, a brilliant writer, who has struggled with poverty since her disability, has shared that a healthcare professional sat at her bedside and urged her to consider death. This was just after Gabrielle’s partner announced he was leaving her because she was too much of a burden and she no longer fit into the life he wanted. 

Doctors can pressure someone to die as in Gabrielle’s situation but also more subtly can confirm a patient’s fears that her life is not worth living and MAiD would indeed be a good medical choice.

Day after day, we participate in a healthcare system and a social support system that does not come close to meeting the basic needs of our most vulnerable patients. However, our role as physicians should always be to first advocate that our patients access all reasonable supports for a meaningful life with no suffering.  But alas, Canada does not seem to prioritize health care and supports for all, and soon, that lack of support will be pitted against an option to access death in 90 days.

Patients entrust doctors to make ethical decisions every day regarding their care and to make recommendations that are always aimed at promoting health and healing. The core role of medicine is to be restorative, not destructive. Advocating for our patient’s health and wellbeing, is a solemn oath we took.

As physicians we help our patients do many things in the context of a trusting, shared, decision making process. Doctors encourage healthy habits.  We refuse to prescribe antibiotics when patients have a viral infection, or opioids on demand. We pull a driver’s license when we have concerns for patient safety and the public good. We refuse to write mask exemptions without good reason. We serve both patient and the common good.

All of this requires courage to not betray the trust society and the patient has bestowed on our profession. Society’s belief in the inherent virtue and ethics of the profession has been the necessary basis of the physician-patient trust.  Would you trust your doctor if you thought they didn’t care about your safety and well-being?

While we recognize patients have the right to ask for MAiD, physicians must not be forced to suggest or forced to facilitate this, when reasonable options for living with dignity exist. We must continue to offer our patients what is good and practice medicine with integrity.

As Dr. Thomas Fung, Physician Lead for Siksika Nation stated, 

“Assisted death should be an option of last resort, and not the path of least resistance for the vulnerable and disadvantaged. Conscience protection is needed in this bill, as no one should be forced to participate in the intentional death of another person against their good will.”

One of the most important foundations of our Canadian identity is that we are a caring, compassionate country. We are proud of our universal healthcare mandate, and we place a high premium on being inclusive and tolerant while working hard toward the accommodation and integration of marginalized and vulnerable members of our community. And yet, if Bill C7 is allowed to stand without amendments, we will be in serious danger of losing this fundamental element of our Canadian identity.

A New Day for the OMA

For many of us 2020 was arguably the worst year we will (hopefully) ever see. The annus horribulus of our lifetimes. But for the Ontario Medical Association (OMA), arguably its worst year was 2016. Reeling from repeated attacks from then Health Minister “Unilateral” Eric Hoskins, the OMA as an organization made a decision to try to play nice by agreeing to a tentative Physicians Services Agreement (tPSA) in an effort to end the war Hoskins started. Unfortunately the deal was substandard, and like everything Hoskins did, was bound to hurt patient care.

Amongst much controversy (which I won’t restate) the tPSA was rejected by physicians. This led to a realization that the OMA needed to change. The organizational structure was archaic, pondering and built on the concept of “politicking” at a large Council meeting of almost 250 people, and passing motions as opposed to developing solutions. A revolutionary change was needed, which required a “disruptor” as leader.

Out of nowhere, in a seemingly vertical career trajectory, came my friend and colleague Dr. Nadia Alam, who wound up becoming the OMA president based on a promise to transform the organization. Her greatest strength was her ability to inspire people that they could be better. Becoming the face of a change agenda, she helped all of us believe that the impossible was possible, and that with hope, and a leap of faith, a better organization could be there for us.

Dr. Nadia Alam, a Past President of the OMA, who became the face of a movement that demanded change for the better.

The first step was to revamp the operational side of the organization. Led by CEO Allan O’Dette, the staff became more organized in cross functional teams, and had a clear purpose delivered to them.

These changes were unquestionably helpful, as seen by the strong response to the COVID19 pandemic. I’ve never heard so many members actually say nice things about the OMA staff as I did over that response. All the staff deserve a great deal of credit for how they came together around this issue, which would not have been possible without the operational re-alignment.

But the governance of the OMA was still antiquated. The bylaws said OMA Council governed the OMA (even though this was a direct contravention of the corporations act). Council has 250 well meaning physicians who give up their own personal time to serve the profession. Unfortunately, trying to secure blocks of votes to pass motions, is simply not a modern way to deal with issues.

The OMA Board had 25 physicians, also well intentioned, who gave up much more personal time and tried to represent the profession as a whole, while mindful of the constituencies that elected them. Twenty-five is just too big for an organization that needs to be nimble, and as dedicated as Board members are, it was apparent that some professional Board Directors were needed to guide the Board so that it could do the best for the profession.

Over the past 18 months, the Governance Transformation Task Force 2020 (GT20) worked overtime to make the OMA a much more modern organization. There were a lot of people involved in GT20, from OMA staff, other physicians, and the consultants. They all are extremely deserving of the thanks of the profession, but to name all of them would use up the word allotment of my blog.

However, I need to make a special mention of the GT20 Co-Chairs, Drs. Paul Hacker and Dr. Lisa Salamon. I have had the opportunity to provide a bit of support to Dr. Salamon, and somewhat more to Dr. Hacker (P.S. Yes, General Manager of OHIP all those K005 claims are legitimate). If not for their dedication and focus, this process could have gone off the rails at multiple occasions.

Drs. Lisa Salamon and Paul Hacker, co-Chairs of the OMA GT20 Task Force and providers of inspirational leadership and dedication the physicians of Ontario

Change is hard. It’s one thing to want change, it’s another to look at proposed changes and realize just how significant they are. Human nature being what it is, many people suddenly had second thoughts or concerns about the transformation at multiple points throughout the consultations and reviews.

But Drs. Hacker and Salamon (and the rest of GT20), stayed the course. They focused on what physicians in Ontario deserve – a leaner, more nimble and strategic organization. An organization where elected leaders come together in a manner that enables them to create positive solutions instead of politicking for votes on motions at a large meeting. An organizational structure that allows for rapid responses when crises inevitably arise.

This past weekend, after many many ups and downs in the process, OMA Council reviewed the proposed changes. As expected, there were lots of well thought out questions about the changes.

However, at the end of the day, one unassailable fact remained. All of the issues that had previously plagued the organization (contracts that paid sub-inflationary increases, not enough progress on relativity, concerns about representation, gender pay gap and much more), would still be around. Yet these were the very things the Council structure had failed to fix.

So the choice for Council was to stick with the old model, or to build a new one. In the end, they followed the advice of someone much smarter than me:

What does this mean for physicians? It means that come May the OMA Board will go from 25 physician members to 8 (plus three non-physician Board members to provide professional guidance). Council has been sunset. In its place, a new model with a Priority and Leadership group (max 125 docs) will exist. The bulk of the policy work and recommendations will be done by Working Groups dedicated to a specific task and which will allow expert members from throughout the profession.

How well will this work? Well it will depend on how much thought members give to the election process. They need to focus on who can represent them best at the various levels. But the reality is that a newer model of representation that is more nimble, strategic and rapidly responsive is finally here for physicians of Ontario. And we all owe a huge vote of thanks to Dr. Alam for starting the change and Drs. Hacker and Salamon for seeing it through.

High Dose? Standard Dose? Doesn’t Matter! Just Get A Flu Shot!

Recently, many physicians offices have been inundated with requests for the so called “high dose” flu shot. I know I’ve had many patients ask in my own office, and this is the result of all the publicity around these shots. Pharmacies were specifically advertising that they had the high dose shots available. Heck some pharmacies even offered customers points for getting your shots. Until of course, they ran out. (Memo to pharmacies – unlike Teslas, generally not a good idea to advertise something you can’t deliver on time).

Of course once they ran out came the inevitable concerns expressed about why people couldn’t get a “high dose” shot themselves. I have also heard some isolated reports in my community about people waiting to get their flu shot until the high dose were back in supply.

But here’s the thing. There is no evidence to suggest that the high dose flu shot is actually better than the current standard dose shot. Seriously.

In 2014, a study was done looking at the high dose versus regular flu shots, particularly in older patients. The study clearly showed that there was a higher immune response in older patients with the high dose shot. But from a clinical perspective, it really only made a minor (although what statisticians will call a statistically significant) difference. 1.9% of people who got the standard flu shot went on to get the flu, and 1.4% of people who got the high dose flu shot went on to get the flu, for an effective difference of 0.5%. All this hype for 0.5%??

But more importantly, that study looked at what are called trivalent flu vaccines. In essence, both the standard and the high dose vaccines in the study were good against three strains of the flu.

However, in Ontario, our standard dose flu shot is a quadrivalent. It’s good against four strains of the flu. The high dose continues to be a trivalent. So the option for people in Ontario is to get a flu shot that has a regular dose against four strains, or a high dose shot that is good against three strains only.

Importantly, there has not been a head to head study between the high dose trivalent and the standard dose quadrivalent used in Ontario. Which means no one really knows which vaccine is better.

Heck even the Public Health Ontario Fact Sheet on flu vaccines states there is “insufficient evidence” to recommend one over the other. There is some supposition about the extra B strain that is covered in the quadrivalent vaccine not being as common in those over 65, and perhaps having a lower disease burden, but it’s not really clear cut.

So what should you do?

As I mentioned in my last blog, you should wait until November to get your flu shot. It now being November – GET IT! If you are over 65 and are unable to get the high dose, don’t sweat it, just get the standard one. Because frankly the protection you get from that is still really really good (I mean why all this fuss over a measly 0.5%??). But don’t put off getting your shot now just to wait and see if more high dose vaccines are coming.

It’s time to protect yourself and your loved ones. Both flu shots are good. Get whichever one you can, and let’s help each other stay safe.

Me getting my flu shot at the hands of my trusty nurse…..

Get Your Flu Shot…..in NOVEMBER

Every year in my office, usually just after Labour Day, the influx of phone calls begins. It’s always the same question -“When are you giving the flu shots?” While it’s easy to grumble about the increase in calls, the reality is that patients who are calling are being pro-active about their health. This is to be lauded as pro-active patients often have the best health outcomes.

Above image from St. Patricks Home of Ottawa.

This year the phone calls came earlier than ever. There’s a general sense in my practice that more people want the flu shot (a good thing) as patients are concerned about winding up in hospital, and contracting COVID19 while there. The fear of a “double threat” in hospitals is high, and I suspect that more people will get a flu shot this year because of this same fear.

This is also compounded by some erroneous information out there about what the flu is. A lot of people who have a cough, or the sniffles or a low grade fever think they have “a touch of the flu.” That’s not really the case. If you have a cold, you will have a fever, cough, and runny nose, but you will not feel like you’re on death’s doorstep.

If you have the flu, in addition to those three symptoms, you will feel like you got run over by a truck twice. The second time because the flu virus will have wanted to to ensure you really really felt it’s presence. Muscles you never knew existed will hurt for days, and it will be an experience you won’t soon forget.

So a lot of people who are getting a cold are concerned that the flu season is already starting. It’s not.

According to Canada Flu Watch, as of October 4, there is an exceptionally low level of flu activity across Canada. The percentage of positive flu tests is a mere .05%, which is well below normal. The flu is not in Canada (yet). I think most physicians would agree that an emphasis on social distancing, hand washing and mask wearing has had a large roll to play in this. Those three things don’t just reduce the spread of COVID19, they also reduce the spread of other viruses, including the flu.

Usually flu season begins around the first week of November with a few cases, peaks in January, is of concern until the end of March, and occasionally drags on into May (see below).

Graph is from the excellent Ottawa Public Health website

However, since the flu numbers are so low this year, it is likely that our flu season will be delayed somewhat. It appears that we can wait just a little bit longer to get it this year (but you should get it)!

The trick with getting the flu shot is timing. It takes your body about two weeks to build up full immunity after getting the flu shot. But, after about 28 days, the immunity starts to wane, slowly perhaps, but it does wane. (Medical nerds out there may want to read this study). Getting the flu shot too soon, means it may wear off before the season ends.

This year, what would be the best thing to do?

First, just about everybody over the age of six months should get a flu shot to protect themselves and their loved ones. The number of people who truly, truly have adverse reactions to the flu shot is very low. Talk to your doctor if you have concerns.

Second, for people who are in nursing homes and retirement homes, it probably is worthwhile getting the shot the last week of October. These patients are truly truly high risk, and it may take them longer to develop immunity.

Third, for most other people in the community, the first couple or three weeks of November are likely the ideal time to get the flu shot this year. My own office won’t even be having our flu shot clinics until November (my patients will get emailed once we firm up the logistics). This is being done to ensure that we all have a reasonable amount of immunity until the end of the flu season.

So let’s all do our part. Continue to social distance, wear a mask, wash your hands frequently (for 20 seconds) and get a flu shot in November. Together, we can ensure that the the double threat remains a threat, and not a reality.

Disclaimer: The opinion above is not individualized medical advice. It’s meant for the population as a whole. If you have specific questions or concerns, speak to your doctor.

Physician Autonomy Essential for Good Patient Care

Several years ago, one of my colleagues was having a disagreement with an external health care agency. She’s a very bright young family physician, and is extremely passionate about one part of comprehensive family medicine care. She really felt the external agency was failing in providing a reasonable level of service for one group of marginalized patients. In particular, she felt the agency’s process for accepting referrals was deeply flawed.

After months of advocacy by her, the agency finally reviewed their intake process. They then pronounced that everything was ok, because 90% of the referrals were processed accordingly.

In response, my tenacious colleague sent an email to all the family docs in the area, asking them for feedback on the referral process. She the proceeded to blast said agency for the 90% processing rate. “If a server at McDonald’s got the order wrong 10% of the time, would he still have a job?” was the line in her email that really got everyone’s attention. As a result, my colleagues sent feedback, the external agency’s response was proven inadequate, and changes were made. In her own way, my colleague was following the wisdom of Ruth Bader Ginsburg:

It also shows, in one neat example why physician autonomy is so important to patient care. Because without that autonomy, and independence, we can’t speak out. We can’t advocate for our patients even if it makes bureaucrats uncomfortable. We can’t expose those situations where patient care has been compromised.

This is, of course, exactly what those who want to take autonomy away from us want. For the most part this includes two types of people. First are health care bureaucrats, who feel that because they control the purse strings, everything should be done their way, and no pesky front line physicians should dare question their judgement or expose their flaws. The second group consists of a small number of physicians, who, while well intentioned, feel that physicians autonomy impedes whatever fancy new health program they want to implement.

Suppose you are an employee in the IT department of a corporation. You make a statement like say, “If our legal department worked at McDonald’s they would get fired because they get orders wrong 10% of the time.” What happens then? Human Resources gets involved, you get called out for making derogatory comments, the CEO might even get involved, you get disciplined and basically told to shut up. Even (especially?) if you are right in the first place.

This is exactly what those who oppose physician autonomy want.

The anti-autonomy crowd feels that physicians resist change. Therefore, the thinking goes, physicians will use their autonomy and independence to impede whatever new program/model/team is being promoted. Hence, autonomy must be curtailed so physicians can do what they are told, and accept whatever the powers that be tell them is good for them.

However, this couldn’t be further from the truth. The vast majority of physicians are open to new ways of doing things. If they truly believe a new process will help their patients, and help their lives, they will adapt. This is why we use new medications, new treatment protocols and yes, newer models of health care delivery than we used in the past. Medicine would not have changed so much in the past 25 years, if it wasn’t for the willingness of physicians to explore newer and different methods of delivering health care.

But as my friend’s example shows (and there are many like hers), what is essential to the provision of good patient care, is for physicians to retain their ability to speak out. My friend saw an area where a health care agency was failing a group of patients. Because she didn’t have to fear retribution in the form of being hauled up in front of Human Resources, she was able to effectively advocate for patients (who in this case happened to be too frail to advocate for themselves). Eventually, due to her persistence, the agency recognized their errors and fixed their flawed process.

In much the same way as we explore transforming the health system again (in Ontario these are to be done with the Ontario Health Teams or OHTs), it is fundamentally important to ensure that physician autonomy is protected in these models. This will allow physicians to speak up if the implementation plans are not going the way they should, or if programs promoted by the leaders are not really going to help patients. While painful for those in charge to hear criticisms, it results in better outcomes in the long run because the new programs will be better, stronger and more effective.

Let’s hope that as the new OHTs are developed (full disclosure, I support the concept) the message of the essential nature of physician autonomy is not lost. Physician autonomy has allowed us to be the best possible advocates for patient care in the past. If we can no longer, as Ginsburg urged, fight for the things we care about, it will be the patients who suffer.

Integrated Health Care: If Not Now, When?

As always, opinions in the following blog are mine, and not necessarily those of the Ontario Medical Association.

Recently, Canada Health Infoway, a non-profit organization funded by the federal government to develop digital health solutions, announced that their electronic prescription solution, PrescribeIT, was adopted by the Shoppers Drug Mart and Loblaw chain of pharmacies. This followed on the heels of PrescibeIT being accepted by the Rexall chain. PrescribeIT allows physicians to essentially send electronic prescriptions from their Electronic Medical Records (EMRs) to pharmacies directly, eliminating the need for paper prescriptions.

Reaction from many physician leaders was generally positive:

Other reports indicate how solutions like this have helped during the current COVID19 pandemic. In England for example, 85% of prescriptions are now electronic, thus helping with social distancing.

While I’m glad progress is (finally) being made, I’m forced to ask one question. Why did it take so bloody long?

As I’ve mentioned repeatedly to various health care bureaucrats over the years, my region (Georgian Bay) has had electronic prescriptions for ELEVEN YEARS now. We’ve regularly been emailing pharmacies and had them message us with either requests, or further information.

Our project additionally allows for pharmacists to become part of the health care team by allowing them limited access to a few important pieces of health information they need to do their job properly. For example, they are allowed access to the patients kidney function tests (knowing that many drugs are excreted by the kidney). In that way, I have gotten much advice about changing the dosage of medicine based on how someone’s kidneys are working.

Building on this project, our local area has also ensured that the our After Hours Clinic uses the local EMR, so if patients have to go there, the physician on call can easily access their charts. The local hospital allows us to house our server in their IT room (increases security because of all the firewalls). The advantage of this is that hospital physicians can access all the outpatient records if needed, and provide better care for patients. Even our local hospice has access to this so that patients can get the care they deserve during their last days.

We were even able, for a three years to have the nursing homes access and securely message our EMRs. The result was an over 50% reduction in admissions to hospital from the nursing homes. The cost of the project was $35,000 per year, but the government couldn’t find the right pocket of money to fund it (sigh – see here for how the bureaucracy works) and so the project died. If you need a cure for insomnia, my talk with more details of how the project worked is here (skip to 7:28):

This then is the real frustration that I, and many other physicians have with EMRs and other Health IT systems. Can you just imagine how much further we would be if all areas of the Province had what a few isolated regions (like mine) have?

For COVID19 for example, our Covid Assessment Centre is on our EMR which means that I get an automatic notification if someone goes for a test. And if that test is positive, it allows for quick notification of the family physician so we can begin the process of contact tracing. It also allows for easy transmission of information of people with febrile respiratory illnesses so that we can track important information like when the symptoms started and ended.

Dr. Irfan Dhalla wrote an exceptional piece in the Globe and Mail on preparing for the winter in times of COVID19. Unsurprisingly, he called for reducing “untraced spread” of COVID19 (50% of all cases have no known contact) and a large part of that solution is a technological one, namely the Canada COVID alert app (available at both the Apple App Store and the Google Play Store).

While he’s correct about that, the reality is that we have more illnesses that we have to deal with than just COVID19. We need to be able to manage cancer, other infectious disease, heart disease, diabetes, the frail elderly with multiple problems and much more. The better we manage those illnesses, the more we can keep those patients out of hospital, which is great anytime, but particularly when there is a risk of hospitals being overwhelmed by a pandemic.

Again, in our neck of the woods the Home Care case co-ordinators are on our system. I often get messages from them about how one of my patients is doing, and requests for information from them (so much easier than faxing). This allows me to remotely address concerns patients are having sooner, and for frail patients, getting treatments sooner can often prevent a rapid deterioration, which will of course, prevent a hospitalization.

So while I really am glad that many more physicians will have access to PrescibeIT, I reluctantly point out that in its current iteration it only does about 65% of what our solution does. I suppose that’s better than 0% which people had before, but it is a testament to the failure of a wide swath of health care bureaucrats over the years that this is the best we have.

Even our system is not perfect. I get miserable situations like some of my COVID19 results come in through OLIS (Ontario Lab Information System) and others through HRM (Hospital Report Manager) and yet others get faxed (!) to me. The auto-categorization in HRM is really a complete joke. I dictated a note on one of my hospital inpatients, and the system classified me as a combined General Surgeon, Anaesthetist and Paediatrician – and while I’m glad the system thought I was that smart, the reality is I now have to go through all this data and spend extra time categorizing it properly.

eHealth Ontario, Ontario MD, Health Quality Ontario, the Ministry of Health and its various digital health teams were all to work co-operatively to build a strong Health Information System. But the reality is that these individual systems do not share information in a way that benefits patients.  The shared vision for health IT in the province (integrated health systems IT) still only exist in pockets around the province. There are lessons to be learned here and steps that should be taken.  All of which would really be beneficial now as we head into a potential second wave of COVID19.

Which leads this old country doctor to wonder: If knowing that a potentially huge crisis is coming our way in health care, will no one step up with a vision to fix Health IT Systems and Integrate Health Care information once and for all? And if not now, WHEN?

Four Years Later, What’s Changed at the OMA?

This past weekend marked the fourth anniversary of the defeat of the 2016 tPSA (tentative Physician Services Agreement) at the Ontario Medical Association (OMA). It marked the culmination of the efforts to mobilize almost 2/3 of the membership to vote against the deal, despite heavy pressure from the then Board to approve it.

In the aftermath of that agreement, there have been some significant and rather seismic changes at the OMA, and it’s worthwhile looking back to see what’s different, and what still needs to be done.

What’s Different?

Many of the more vocal critics of the OMA from the past have actually become more involved in the OMA. Heck from Dr. Shawn Whatley (2017) onwards, all of the Presidents of the OMA have been people who took a much more different approach to things than Presidents in the past. Frankly, that’s been good for the profession despite whatever tension it may cause at the OMA. Current President Dr. Samantha Hill and President-Elect Dr. Adam Kassam appear to be carrying on this path (which is good).

The Presidents are elected by Council, not from the Board like previous. It’s important to ensure that the President is not elected by a small group, and I’m glad to see it’s being proposed the President will be elected by the members going forward. The Board must listen to the President, because they represent the will of the members.

There has also been a significant shift in how the OMA is structured. In the past the OMA had something like 50-60 committees, all of which were chaired by a Board member. This led to the Board being too operational. Now the Board is down to four committees (Finance, Human Resources, Governance and Strategy) in keeping with the oversight function a Board must have. The total number of committees have been reduced to about 15.

The CEO, Mr. Allan O’Dette, has made a number of operational changes as well. He has brought in a number of cross-functional teams (essentially teams with members from each department) to deal with issues. These efforts paid off in fighting for changes to Bill 10, and the push to bring back arbitration after the government took it away. However, clearly the biggest impact of this approach was in how the OMA handled the COVID-19 pandemic.

I can tell you that I have never, ever seen so much praise for the OMA as I did around the COVID-19 response. Led by Dr. James Wright and Dara Laxer from the Economics, Policy and Research arm (and supported by just about everybody else in the organization – too many to mention but always in my thoughts with immense gratitude) they provided physicians with education, support, resources and timely updates.

I don’t believe the OMA could have mounted a response as strong as this if it was still structured the way it was in the past.

What Still Needs to be Done?

First and foremost, the last set of governance changes endorsed by the Board, must pass through Council. These changes will result in (most importantly) a reduction in the size of the Board from 26 physicians to 8 physicians and 3 non-physicians. Having been on the Board for the past 2.5 years, I can tell you first hand that it is extremely difficult to have a productive meeting with such a big Board. A leaner Board, with some true professional Board members to guide them can dramatically increase the productivity of the Board, and allow the Board to focus specifically on membership wide issues.

The restructuring of the Council to the General Assembly (GA) similarly is essential to the proper functioning of the OMA. The biggest selling point to me, of the GA, is the creation of the Working Groups. In the past, Council would appoint committees but they would be made up members of Council. Now, the Working Groups can include members of the entire profession. So if you have an interest in a specific policy, you don’t have to run for the GA. You can just go into a Working Group, and focus on your area of expertise. It’s a great way to broaden member engagement by allowing members to participate in areas of interest to them, and not take on the full responsibility of a GA or Board member.

The COVID-19 pandemic, and the resulting change to Spring Council delayed these changes, but we need to get them passed.

I will say, that while culture change is occurring, there is always the danger of falling back into bad habits. For example, the OMA staff (who I will say have really done an excellent job on multiple issues) will probably continually need to be “nudged” to focus on skills based recruitment. If the OMA sends out a call for members to join a specific committee, it is human nature to look at the applicants, and then pick people you already know because of their “institutional knowledge”. But the reality is that to serve members best, it is often important to pick new and different people, who also bring a broad set of skills to the table. It’s a hard change to make, and we must guard against slippage into old habits.

The OMA must continue to get bolder. Heck the Mission Vision and Values of the OMA clearly states that the organization will be bold, and will courageously pursue new ideas and solutions. Part of being bold, is taking risks. Again, there has been progress on this front at the OMA, but when you are historically a risk averse organization, it’s easy to take the path of least resistance on issues.

Finally, the last little bit of what has to continue to happen falls, quite frankly, on the rank and file members. Over the past few years, there has been a gradual increase in the number of members who vote in elections. This is a GOOD thing of course. However, we always need more members voting, and frankly, members need to THINK about who they are voting for.

Are you voting for someone just because they seem to spam you inbox/twitter feed/facebook page with and seem to “want it”? Are you just picking alphabetically the first candidate so that you can just get the damn website to go to the next page so you can finish off your renewal of membership? Have you actually read the position statements and seen the videos?

This year in particular, if the proposed changes do happen, it will be absolutely imperative for members to pick the right candidates for the Board and the General Assembly. Read all the position statements. Find the candidate you identify with. Then vote for them.

The OMA’s transformation is happening, slower than many would like, and often times with two steps forward and one back, but it is happening. To continue to make progress, the members will need to do their bit.

This blog was inspired by Dr. Graham Slaughter, who reminded me of the fourth anniversary. Graham is one of the smartest people I know, a exceptionally dedicated father and husband, and has been a tremendous help help to myself and others behind the scenes. Pictured with his new daughter Nora.

The “Feminization” of Medicine has Widened the Gender Pay Gap

Dr. Michelle Cohen (pictured left), a family physician from Brighton, Ontario guest blogs today. Opinions are hers (although in this case I share them). This article was initially published in the Medical Post and is reproduced here, with her permission, so that it is “ungated” and available for all.

What happens when certain types of medical work become synonymous with women’s work?

Women have moved into medicine in huge numbers over the past four decades. This is usually viewed as a good news story of social progress in a profession that had either banned or severely restricted female entry well into the 1960’s.

In this excellent paper by Dr. Elaine Pelley and Dr. Molly Carnes, the authors begin with a discussion on gender segregation in the broader workforce (in the US). It generally decreased thought the 20th century  with the entry of women into the workplace, but then stalled in the mid-90’s and ticked back upwards slightly.

When a large number of women enter a previously male dominated occupation, it will quickly move towards female predominance. This phenomenon is known as “tipping” and it has not been shown to happen in reverse (i.e., men don’t tend to take over fields seen as “women’s work”). When an occupation hits the gender tipping point (which varies roughly from 13-45% female), entry of men rapidly declines. This is the pattern demonstrated by teachers, secretaries, bank tellers, etc.

In academia and professions requiring high educational attainment, a tipping phenomenon occurs at 24% female. In other words, once a field is one quarter female, men start to lose interest in it. It loses prestige and the ineffable qualities granted by gender exclusivity.

What’s the evidence that a field loses prestige with female entry? At around the 38% female mark, interest from both men and women starts to decline. Research also shows an inverse relationship between how challenging a field seems and how many female PhDs are in it.

This is where we need to talk about the #GenderPayGap. Because not only do female dominated occupations earn less than male dominated occupations, historical data shows that each 10% increase in female share results in a 0.5-5% decline in earnings.

The gender pay gap is at its simplest about paying women less for equal work. But the gendering of occupations plays a major (and often overlooked) role. Research on high skill occupations shows men essentially take a pay cut when they enter female dominated professions.

This brings us to medicine. A profession with dramatic gender segregation among its specialties and little-to-no introspection on the impact of this phenomenon. In Canada, female representation among medical specialties varies from roughly 10% to 75%.

Historically, once women were allowed into medical school, they were immediately shunted into the specialties that seemed appropriate. Ones that involved babies or so-called “soft skills” like counseling. They were strongly discouraged from entering macho fields like surgery.

I say “historically” but of course, these ideas remain as strong as ever (that’s what happens when your industry lacks introspection on its own subculture). Ask any woman in medicine and she will tell you lots of stories like this one.

Naturally, we lack data on the gender segregation of specialties over time. If you can’t see a phenomenon, you can’t study it, right? Fortunately, Dr. Pelley and Dr. Carnes dig into historical data, showing that U.S. gender segregation in medical specialties has remained static since the 80’s—that’s my entire lifetime. American medicine has remained frozen in the same sexist ideas about women and men’s “natural” skills since the Reagan years.

Is Canadian medicine any better? We haven’t analyzed historical data (yet), but I think you know what I would say.

This paper does what few have: It looks at how feminization of a specialty impacts its relative earnings over time. This is such an important analysis and I can’t believe we don’t have more like these.

For example, pediatrics went from 22% to 63% female since 1975, but orthopedics has remained nearly the same. Subsequently, pediatrics went from earning 93% of the average MD salary to 71%. Meanwhile orthopedics went from 160% to 180% of average. Or consider obstetrics and urology. Obstetrics has lost relative income since the 70’s while going from 8% to 57% female. Meanwhile, urology has maintained its relative earnings (125% of average MD salary) while remaining at >90% male.

While I haven’t looked at historical data in Canadian medicine, I have done a lot of work analyzing the gender breakdown in specialties and their relative incomes. Those results will be published next month, but let me summarize it quickly now:

Gender segregation in Canadian medical specialties is a major factor in the gender pay gap. There are many other relevant factors at play, but the shunting of women into “female-friendly” specialties while discouraging entry into male dominated specialties plays a huge role.

We need more discussion on how women entering a field devalues it. We also need to broaden this analysis to include all of health care, which is full of women doing vitally important and shamefully underpaid work.

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