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.

Don’t Like Mob Rule? Then Work to Fix Inequality

The past few months have seen a tremendous wave of social unrest in the United States, and some in Canada. This was spurred by the killing of George Floyd, an act so heinous that even noted racist Donald J. Trump called it a terrible thing. A seemingly endless stream of video evidence of discrimination and violence against not just Black people, but BIPOC (Black, Indigenous, People of Colour), meant these protests have carried on for months, and even threatened to end the seasons of professional sports leagues.

While the protests have largely been peaceful, there has been violence in some American cities. Additionally, many American protestors have taken to tearing down statues of those who they view as oppressive or racist historical figures. Canadians were confronted with this happening on our own soil when the Coalition for BIPOC Liberation tore down a statue of Sir John A. MacDonald in Montreal.

Reaction to this act in Canada was pretty swift and, sadly predictable. Numerous people have decried the action as “mob rule”. Media types who work for outlets with a penchant for Islamaphobia compared the protestors to the Taliban. What better way to both vilify protestors whose philosophy you don’t agree with, than by using dog-whistle type comparisons to get at Muslims you don’t like as well. Kills two birds with one stone, right?

Even our own inept Prime Minister, Justin Trudeau, stated that “actions like this have no place” in Canada. Of course we all know what he truly thinks of indigenous people by the way he brazenly attacked his former Justice Minister Jody Wilson-Raybould. Even the pro-Liberal Toronto Star criticized him for it. As for what he thinks of people of colour, well……

The usual argument against these protestors is that they should protest peacefully instead, and of course that allowing this “mob rule” will mean the mob will “come for you and your family” next. Not being satisfied with just going after Muslims, the extreme far right anti-BLM crowd throws in a nice dose of anti-Semitism as well, by suggesting these actions are funded by George Soros.

Generally, there are two types of solutions presented by those who claim they don’t want “mob rule”. The first is to demand a strong response. “Law and Order” is needed they scream. “Keep arresting people until there is no one left to lock up!” Peaceful protests are ok in their eyes (not a peaceful protest like cancelling some basketball games, of course, that’s just wrong), but the tearing down of statues is anarchy and must be met with force.

Many of these indignant types forget that the first tearing down of statues in America happened five days after declaring independence, on July 9, 1776. A “mob” in New York tore down the statue of King George to protest his oppressive rule and unfair treatment of Americans. Sound familiar? Undoubtedly the British viewed such an act as anarchy. Funny how those opposed to the protests don’t mention this.

The second solution offered is one that is promoted by people like Christian Walker (son of former NFL player and Trump supporter Herschel Walker, who is Black) and Sheriff David Clarke (also Black). Their suggestion is that to avoid brutality, one should show follow directions from the police, and learn to respect to the police and institutions. “When a cop gives you a lawful command, OBEY IT.“thunders Clarke.

However, not 30 minutes after reading a Facebook post in which Clarke is quoted as saying “if you want to protect your child, teach them respect”, I came across the following article on TMZ. Have a look at the videos. In the first video, a white man is doing anything but showing respect to the police officer. He is hurling insults, being threatening, using abusive language and doing everything that Clarke and Walker say you should NOT. While the police officer has his gun out (and I would say understandably, given the circumstances), there is no shooting and the individual is talked down.

The second video, is jarring. A black man is doing EXACTLY what Clarke and Walker suggest. He is standing quietly, not resisting, hands on his head so that the police can see that he is making no sudden or threatening movements. In short, he is co-operating, following the rules, and, as Clarke directed, obeying the police. His reward? To be viciously assaulted by a cowardly drop kick to the back.

And that one comparison symbolizes why the protests are happening. Despite doing what you should do in a lawful society, and following the rules, people are still being targeted for being BIPOC. That’s just the physical violence. All sorts of evidence exists that there is economic discrimination against BIPOCs.

Now to be clear, I am not a fan of violent protests or mobs. Mobs do destabilize society and can cause tremendous unrest, economic damage, and physical harm to innocent people. It’s imperative to find a way to stop them.

But stopping them also means acknowledging the reality that mobs and protests like these only happen because the way society is set up leaves a group of people feeling as if they have no hope for a better future. American Revolutionaries tried to legally express their grievances with England about not being treated equally to other British subjects for years prior to taking violent action. BIPOCs have been asking for true equality for decades (if not centuries). The reality is people usually only turn to violence if they have tried all other methods, and, if they feel there is no hope of a better future. It’s the despair that drives this behaviour and it’s the despair that must fundamentally be treated.

We must prevent “mob rule”. Doing so is the only way to preserve a safe, healthy and strong society. But doing so requires all of us to take a good hard look at persistent inequalities in our society, work to fix them, and thus give hope to people who currently feel none.

History teaches what the alternative is, and we don’t want to go there.

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

ConquerCovid-19 a True Canadian Success Story

Not all heroes wear capes.” – It’s an expression often found on the internet.  It of course, refers to the fact that you don’t have to be Batwoman or Superman or whoever, to do some good in this world.  

During the Great Pandemic of 2020 of course, this phrase is often used to describe those of us who provide health care on the front lines. Cleary, the physicians, nurses, first responders, PSWs, support staff, environmental services staff and many others who provide front line care during this historically difficult time are heroes.  They inspired me during my term as President of the Ontario Medical Association (OMA), and they continue to inspire me now with their dedication and passion.

While there are many other heroes out there, I want to give a shout to one group that in many ways represents Canadians at their best, ConquerCovid-19.  

The full story of how ConquerCovid-19 came to be can be found here. The short version is that they started out in mid-March as the brainchild of Sulemaan Ahmed and his wife Khadija Cajee.  They heard their physician friends complain about the lack of Personal Protective Equipment (PPE) in their clinics, and wanted to help.

Neither one of them is a stranger to advocacy for social causes. They both are already heavily involved in fighting the ridiculous No Fly list in Canada that erroneously lists thousands of children and innocent people.

Sulemaan, Khadija and four of their friends formed ConquerCovid-19 and using their business connections ( Executive Training with ServoAnnex) asked companies who had PPE to donate them to health care providers.  Almost immediately, their friends and their friend’s children volunteered to help out (with apologies there are too many to list).  The organization grew steadily and quickly.

Then a medical student who also was worried about the shortage of PPE heard about their endeavours, and offered to help out.  As brilliant as medical students are, normally one extra student wouldn’t cause a wholesale change.  But said medical student also happens to be the greatest female hockey player of all time, Hayley Wickenheiser.  Next thing you know, she gets her friend Hannibal King….Green Lantern….. Deadpool… Ryan Reynolds involved and the star power catapulted the success of the organization.

A quick look at the their twitter feed shows that they have donated PPEs to organizations that deal with at risk youth, medical schools, support services for frail seniors, nursing homes, multiple child and youth services, shelters for new immigrants and refugees, rural and remote areas of the province and much more.

What’s more, they suddenly found people willing to donate supplies other than PPE. Instead of saying no, ConquerCovid-19 took on Hayley Wickenheiser’s mantra (Get Sh-t Done!) and took non-PPE supplies and found good homes for them. Have some extra computer tablets – send them to nursing homes so residents can communicate with families. Feminine hygiene products – send them to Women’s Shelters, and much more. There has also been a significant amount of cash raised from sales of what Reynolds calls “a boring shirt”. Ok he was more colourful than that, but check out #boringshirtchallenge.

All of this was in addition to the almost 500,000 units of PPE donated to medical clinics across the Province in co-ordination with the OMA. I was honoured to have been invited their April PPE drive where I saw the group in action.

That’s when I realized the best thing about ConquerCovid-19.  They exemplify what Canada is all about.

It’s no secret that we are so living in a time where there is a tremendous, un-precedented call for social justice.  The Black Lives Matter movement has forced us to confront and deal with inherent systemic racism against Black Canadians. In particular, Statistics Canada data shows that we are failing yet another generation of Black youths. Alas there are too many such stories in Canada.

Our record in dealing with our Indigenous population is disgraceful, with even the United Nations calling the housing conditions abhorrent.  We have systemically discriminated against them, and there are too many individual stories to mention. There has also been a rise in Islamophobia and anti-Semitism.

Many will see this and despair for Canada.  Make no mistake, all of us need to continue to be vigilant and work to improve our country.  But when I think of Canada, I will, instead, think of ConquerCovid-19, and how it exemplifies what Canada is all about.

You see, Sulemaan and Khadija are Muslims whose families immigrated to Canada.  The leadership group (whom I was fortunate to meet) includes Jews, Sikhs, Christians and those that are, let’s say, ill defined when it comes to religion.  They have people of all colours in their organization.  

ConquerCovid-19 is not just a snap shot of Canada in 2020, it’s a snapshot of the best of Canada.  While we struggle to deal with our failings as a nation, rather than look with despair on our country, we should look to the hope that organizations like ConquerCovid-19 provide.  To my mind, there is no other country on this planet where such a diverse group of people could come together, find a common cause that is rooted in charity and selflessness, and work co-operatively for the benefit of all.

The strength of Canada lies in it’s unique multi-cultural nature, where our differences are celebrated, not denigrated. Where our basic humanity, tolerance and kindness is the common thread that unites us all. That is what Canada is all about, and that is what ConquerCovid-19 exemplifies every day by their actions.

Thank you ConquerCovid-19, for reminding us of the promise that is Canada.

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.

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.

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.

Medical Students Have the Power to Inspire

The article below initially appeared in Scrub-In, a magazine for medical students published by the Ontario Medical Association.  It’s being reproduced here.  Pictured above are the three medical students I had an impromptu meeting with, from Left to Right, Zak Haj-Ahmad, Harris Sheik and Nader Chaya.

Life is funny sometimes.  I was wondering what to write for Scrub-in.  So, I did what most people my age do when in a funk – I went to eat carbs (in this case Pizza).  As it happened, I had a chance encounter with three medical students from the University of Toronto.

Like most medical students, they wondered what to specialize in, whether there will be work in their chosen field, how government regulations and changing scopes of practice will affect them, and more.  But despite that, what was plainly obvious was the passion, enthusiasm and pure joy they exhibited at simply being in Medical School, and the gratitude at being chosen to join our noble profession.  I was inspired by them, as I remembered the wonder I felt when I first got accepted into medical school.

I also asked them what they thought medical students would like to hear about.  I was relieved that it was similar to what I was thinking.  Medical school has many ups and it has many downs.  It can bring joy tremendous joy and pride.  It can bring you tremendous sorrow, and sometimes pain.  But here is what helped me, and I think will help you.

  • Try to stay on an even keel. I realize that many of you are watching your grades fall seemingly like guano from stalagmites or seeing incredible triumphs  like your first successful procedure. But remember – things are never as bad as they seem.

 

  • Don’t forget self care. Not only does self care mean the usual – eat right, exercise, take time for yourself., It also means don’t neglect your friends and your family.  They can support you through the tough times.  Self care also means taking care of things like planning for the future. It may seem premature to get insurance and start saving for retirement (especially when you have $200,000 in debt) but small investments in those now can pay off significantly in the future, and give you more peace of mind than your realize.  Visit our Advantages Retirement Plan™ website or contact an OMA Insurance Advisor at retire@omainsurance.com to get started.

 

  • Remember that everyone has a role to play here (my thanks to future doctor Zak Haj-Ahmad for helping me crystalize my thoughts on this one). Look, when you graduate, the simple fact that you get to use “Dr.” before your name will afford you a tremendous amount of respect and privilege in the eyes of the general public.  But with that respect comes a responsibility that you have to ensure that you treat your patients (and others) with kindness, humility and basic human dignity. Everyone has a role to play in a health care team (student, teacher, nurse, janitor etc). Make sure you exhibit the kindness and empathy you expect from doctors to others at all times, particularly when things are stressful.  It will reflect well on you, on our profession, and I find it will help you become a better person.

I want to wish all of my future colleagues the best of luck as you pursue life in our great profession.  Follow me on twitter @drmsgandhi.

If you want to know more about the OMA and how we can help you, please visit our website or contact Jenny Cheadle at Jenny.Cheadle@oma.org