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

 

Governance Transformation Essential for the OMA

 

Note: The following guest blog was was written by Dr. Paul Hacker and Dr. Lisa Salamon (pictured above).  While the opinions are theirs, I happen to share those opinions as well.

We, the co-chairs of the Ontario Medical Association’s Governance Transformation 2020 Task Force (GT20), welcome discussion and debate about the recommendations for change in our report, Better Together. These recommendations were made in response to the broad input from council delegates, members, board directors, senior OMA leadership and external stakeholders.

Recent reports about these recommendations have, unfortunately, included inaccurate statements leading to erroneous conclusions. The report, including a summaryand FAQ document, is available in the links or on the OMA website (here).

We would like to highlight for OMA members, the changes that we hope to see in 2021 if these recommendations are endorsed at the council meeting this week and receive final approval at Spring council in May 2020.

Members will directly ratify all negotiated Physician Services Agreements (PSAs)

Currently, council has the authority to ratify any negotiated PSA. In the future, this responsibility will rest with you, the member. Contrary to other reports, if these changes are passed, the OMA would introduce a new bylaw requiring member ratification that could not be overruled or ignored by the board of directors.

Fully informed members will directly vote for their president-elect and directors. Currently, members elect a small proportion of directors to the board, based on where you practice; other members and council elect the rest. In the future, members will vote for all directors, informed by a standardized profile generated by an independent third party.

Members are likely aware of their current role regarding the election of the president-elect: participation in a non-binding member poll while council makes the final selection. In the future, you will vote directly to choose your president-elect.

A collaborative general assembly will replace council

Council, governed by outdated parliamentary rules which promote factional disputes, will be replaced by a general assembly that still represents members through section, district and forum delegates, but seeks to work collaboratively to identify the priorities most important to members.

Members will be given new and enhanced opportunities to contribute to time-limited working groups. This ensures that the work of these groups is relevant to you and other members and uses the expertise found within the membership to help guide the OMA.

The OMA will become more nimble, able to respond to emerging issues effectively:

A streamlined governance structure will result in a more agile organization. Members should notice that communications are clearer, the OMA acts more decisively and that it advances solutions that make sense to members.

Both of us became involved with the OMA in 2016/17 because of frustration with the results we, as members, were seeing. As we got more involved, it became clear that the underperformance of the OMA was not due to a lack of effort. The OMA had stagnated under a governance structure that had grown out of date and was no longer responsive to its members. And in 2019, members told us nothing had changed.

We believe that it’s time for an upgrade. We invite and welcome all members to join us in this change.

Dr. Paul Hacker and Dr. Lisa Salamon are the co-chairs of the GT20 Task Force.

PATIENT SAFETY AND CONTINUITY OF CARE MUST COME FIRST

On October 22, an article by Shawn Jeffords, reprinted in HuffPost online, talked about the government’s call for feedback on letting nurses prescribe certain medications.

This is a critical issue and one in which I and the Ontario Medical Association (OMA) Board are actively involved.  For us, patient safety and continuity of care must come first. The ultimate goal of any scope of practice change should be to improve and enhance high quality patient care, not just to provide convenience.

In the summer and fall of 2018, the OMA shared our concerns directly with the College of Nurses.  We are now completing our submission to the Ontario government.

In short, we welcome and appreciate the value all health care providers bring to patients and the broader healthcare system. I personally have been strongly supportive of nurses in the past as there is simply no way I could look after patients without their help.  Both I and the OMA encourage collaborative, team-based, patient-centred delivery of health care. To that end, the OMA evaluates any changes in scope based on the OMA’s Set of Principles outlined below.

The ability to seamlessly share information is equally critical to the continuity of care for patients. Ideally this information would be shared through electronic health records, so this should be a consideration when looking at any changes to prescribing authority. A complete medical history, including all diagnoses and treatment information, is essential for any practitioner to effectively treat a patient.

OMA Set of Principles

OMA’s highly rigorous process for evaluating scope of practice changes involves using the following key principles. Scope changes should:

  • Be consistent with the knowledge, skill and judgment of the professionals involved
  • Be subject to a rigorous regulatory structure
  • Support a truly collaborative, team-based approach to care as opposed to parallel care
  • Not raise patient safety concerns
  • Be accompanied by system initiatives/supports to ensure that no health care provider is unreasonably burdened with complications arising from expanded scopes of practice from other professions
  • Be subject to stringent conflict of interest provisions
  • Be applied with consideration of current best practices and lessons learned from other jurisdictions
  • Be applied with consideration to cost effectiveness at a health system level
  • Promote inter-professional communication and information sharing
  • Promotes continuity of care
  • Promote positive relationship with patient
  • Should be subject to system evaluation to determine if leading to positive outcome.

To some, the above principles may seem overly onerous.  Others may view this as “turf protection”.  But the reality is that multiple studies have shown that the best care provided to patients is when continuity of care is maintained.  This does not mean that you must get a treatment from your family doctor, it means that your family doctor must be aware of what treatment has been given, so that it can be part of your medical record to inform future decisions made about your care.

Also, to be clear, there are many instances where the changes in scope of practice have been beneficial.  My own ophthalmologist has a collaborative relationship with three optometrists that provides continuity of care, and ensures patients get care in a timely manner.  These type of unique models (not just in ophthalmology) occur throughout Ontario, and must be supported.

The priority of every doctor in Ontario is the health and well-being of their patients. We care for more than 340,000 patients every day.  There is simply no substitute for a doctor.  In order to ensure our patients get the best care, it is important that policy decisions always focus on appropriate high quality health care.  It is this way that we can help to fix the health care system and solve critical issues like hallway medicine.