Community doctors key to successful vaccination rollout

The following blog was co-written by Dr. Samantha Hill (current OMA President) and Dr. Adam Kassam (OMA President-Elect). It first appeared in the online version of the Toronto Star on January 11, 2021 and is reproduced here with the permission of the authours.

Images of elated physicians and other health care workers being immunized has been an emotional experience for our community. Our professional stoicism has given way to more fundamental and broadly shared human feelings: joy and optimism. 

For close to a year now, we have had to work at the very tip of the spear against the pandemic. This dangerous, exhausting and unpredictable work has taken its toll. That is why the vaccine represents a literal infusion of hope for us, our patients, families and communities.

We are thoroughly delighted for every colleague, long-term care resident and vulnerable person who is now a little bit safer. However, collectively, we are still a long way from defeating this disease. As we encounter record highs of cases, hospitalizations and — sadly — deaths, only a fraction of Ontario’s physicians have received a first dose of the vaccine. 

For understandable logistical reasons — which include the need for special cold storage — most of the first vaccines were administered in tertiary hospital centres, which have admirably risen to the immense challenge of organizing the safe and efficient deployment of the vaccines. 

Getting everyone vaccinated successfully relies on two key factors: the federal government’s continuous and predictable procurement and delivery of the vaccines to Ontario, and the provincial government’s ability to distribute and administer the vaccine to Ontarians.

To that end, as approvals for other vaccines occur nationally and vaccine supplies ramp up across the country, we will need to move beyond hospitals to build capacity to be provincially successful in rapidly immunizing our population. These centres are already stretched thin, simultaneously treating a growing number of sick COVID-19 patients and the usual hospital health care needs of Ontario.

Which is precisely why, the next leg in this crucial vaccine race requires a co-ordinated community effort to vaccinate front-line health-care workers and the vulnerable patients both within and outside of congregate care settings.

Approximately 60 per cent of physician services occur outside of the hospitals. Many of these community doctors — both primary care and specialists — have direct knowledge of their vulnerable patients. They have developed relationships, credibility and bonds of trust through their continuity of care, all of which are crucial for success of any province-wide vaccination program. Grassroots, community doctors will also be essential to co-ordinating the necessary two-dose schedule.

Community doctors must have clarity on access to vaccines, not only for their own well being, but also for planning purposes for their patients. They have been caring for their communities for years, and these doctors are an invaluable resource with experience, expertise and capacity that must be leveraged. Even now, in this next stage, Ontarians deserve a trusted medical professional — many of whom come from, live and work in diverse communities — upon whom to rely.

This pandemic has challenged every facet of our society. In Ontario, thousands of people have contracted and died from this terrible disease. Our already-precarious health care system has been buckling under this added pressure. Disruption to businesses, communities and families has been widespread.

We all desperately want this devastation to stop. Our path out of this is with these vaccines. Doctors are, unfailingly, at our posts and prepared to help. While this pandemic has been a marathon, we need to now think of the vaccine rollout as a sprint. Because in this race, lives and livelihoods are at stake.

Message from OMA President: STAY HOME

Dr. Samantha Hill

The following blog was written by Dr. Samantha Hill, a Cardiovascular Surgeon, owner of a Masters in Biostatistics and Epidemiology AND another Masters in Health Practioner Teacher Education. In her spare time she is the current President of the Ontario Medical Association, which represents 44,000 physicians, medical students and residents.

It’s time for some serious advice from your doctors to ensure that everyone has the safest and happiest holiday season.  

The recently announced lockdown is effective Boxing Day, but Ontarians do not have to wait.  All of us can, and should, take action now, including cancelling plans to visit family and friends on Christmas.

COVID-19 is serious.  The numbers of Ontarians confirmed positive for COVID, hospitalized, admitted to the ICU, and ventilated continue to rise dramatically.  Hospitals are again reducing non-emergent care and preparing for surge capacity.  LTCs are overwhelmed and calling out for help, as their patients, our elderly, suffer.

Clearly, we need to do better.

This spring, we demonstrated severe lockdowns save lives from COVID.  But, we failed our most vulnerable, saw high health costs (late presentations of other illnesses, marked increase in mental health challenges, and a staggering pandemic deficit of health) and severe economic consequences.

In September, we moved indoors again. Despite most people following public health guidelines, labs and contact tracers are again overwhelmed.  Lockdowns are present and imminent.

Let me be clear, that means we are failing. 

Lockdowns are a last resort, imposed when we fail to live safely within tenuous new normals and escalating precautions are not enough to protect us. There is no space for blame.  We are all in this together, and we all have a role to play.

I find myself needing to remind you, that during lockdowns, essential workers still go to work: your doctors, all front-line health-care providers, teachers, but also “invisible” essential workers who stock grocery store aisles, work the cash register, service the TTC, support LTCs and hospitals, etc. Many ride the TTC to do so.

Doctors know that being deemed essential does not equate with being safe from COVID-19.  A grocery store is no safer than a clothing store.  Lunch in the work breakroom is no safer than lunch with others anywhere else.   An hour on public transit is no safer than a one-hour flight. Over the past nine months, we have seen outbreaks, illness and deaths stemming from essential services.  These services stay open because we need them.

Essential workers are exposed to increased risks for the well-being of others.  We decided we can’t live without them. So we have an obligation to protect them, not just bang pots.  Their lives, literally, depend on our choices.

So how do we keep people safe? You already know: Mask up, wash your hands, maintain social distancing.  Always choose the safer activity, skip the social event or stay home.  When we get it right, we decrease the spread of COVID in our communities, avoid lockdowns, protect our most vulnerable, our essential workers and everyone else, without sacrificing everything else.

A COVID vaccine is on the way for all of us – we can finally see the light at the end of the tunnel.  But we are still squarely in the tunnel, and will be until the majority of Ontarians have been vaccinated (and the timeline for this is the end of 2021).  Worse though, one-third  of Ontarians are planning to ignore the public health recommendations to not socialize over the holidays.   Worst-case modelling projections predict nearly 10,000 cases daily by January.  Our choices today determine that.

So, this doctor’s advice? 

  1. Assess the risk and benefit of each action, job, trip or interaction, particularly during the holidays.  Is it worth the risk not just to you, but to all of Ontario? For those scanning: ALMOST EVERYONE SHOULD STAY HOME FOR THE HOLIDAYS.
  2. When worth the risk,
    • wear your mask and distance yourself from those who will not 
    • wash or sanitize your hands frequently
    • stay two metres apart
    • minimize the time you spend in close quarters with others, the number of people involved, how often you interact with others.
  1. Don’t grow complacent.  Small actions matter:  start a line when a store is full; redirect friends to gather outdoors or skip eating; keep your kid with a runny nose home; no one can tell if it’s just a cold.
  2. Keep getting tested for COVID-19.  We need to know where it is to eradicate it.

2020 has been a long, dark, year but the vaccines are arriving, bringing renewed hope.  Let’s all do our part and ensure that as many of us as possible make it into the daylight 2021 promises.

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.

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.