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.

There Is No Substitute For a Doctor

Note: This blog was originally published on the OMA website.  It’s being reproduced here for those of you who do not access that site.  I have also added commentary on the report about the growth in physician numbers.

Every health care journey is different, but they all have one thing in common. They all involve a doctor. There is nothing pleasant about getting hurt or getting sick. But in Canada, there is something extremely comforting about knowing that doctors are there for us in our time of need.  Patients understand the value of doctors.  They understand that it takes a doctor to diagnose the problem, determine the appropriate course of care and follow them throughout treatment.

Doctors have a minimum of ten years of post secondary education before they enter the profession. They continue to enhance their skills throughout their practice through regular education programs. This training and expertise are what differentiates them from other health care providers. Many providers play a critical role as part of an integrated health care team, but it takes a doctor to identify – and often deliver – the continuum of care needed.

Ontario doctors are on the front lines of our health care system.  We care for 340,000 patients every day, and the health and well-being of those patients is our absolute number one priority.  We know what is working within our system, and we know what needs to be fixed.  We understand that changes being made to health care have to work for patients in real-life situations, and we understand better than anyone that cutting physician services means longer wait times and reduced access to care for our patients.

That last point is critical.  Ontario doctors carry a heavier workload than doctors in many other jurisdictions in the world.  We currently have 2.3 physicians in Ontario for every thousand people.  Europe has, on average 3.9 physicians for every thousand people, with countries such as Sweden and Germany up over 4 (source: World Health Organization’s Global Health Workforce Statistics).  Despite this heavier workload, and because of the dedication of Ontario’s doctors we still manage to provide the best possible care we can to our patients.

Not only do I want to preserve that, but I want to improve on that.  While I’m grateful to see the recent report that suggests the number of physicians is increasing faster than the general population, we still have a long way to go.  Europe also has many structural differences in how they deliver health care (some of which we should copy – a topic for another blog).  But even with those differences, they need more doctors per capita.

Research has shown that a high quality health care system needs strong physician leadership.  Specifically, physician leadership in terms of system design, governance, and implementation is vital.  A doctor-led system that focuses on integrated care provides better quality at lower cost, and this is what we need to build in Ontario.  The patient-centred system of the future, today.

Ontario doctors are willing to help build, and lead, the health care system that Ontarians deserve.  A system that will improve patient care and health outcomes and reduce wait times.  A system that will recognize and meet the needs of rural, Northern and underserved communities.  And a system that removes unnecessary administration and red tape to enable more efficient and effective delivery of care.  It takes a doctor to lead a patient throughout his or her health care journey, and it takes doctors to lead Ontario’s health care transformation.  Because ultimately, there is no substitute for a doctor.

My Experience With The Vaccine Hesitant

Dr. Samantha Hill

The following blog was written by Dr. Samantha Hill (pictured above), President Elect of the Ontario Medical Association.  The blog reflects her opinion and not that of the OMA.  It was published in the Medical Post, but is being republished here for those who do not have access to that site.

It’s an interesting experience, being yelled at by a room full of angry people.    It’s not something physicians encounter regularly.   Professional criticism is usually subtle: askew glances, rejected papers, absent promotions.  Decades of schooling had not prepared me to stand in a room full of people yelling “shame”.

On Monday, I (and others) deputed at the Toronto Board of Health on the merits of vaccination.  We were met by a large crowd of angry people.  I was heckled, jeered at, and even photographed for later attacks on social media.

The aggressive opposition was unexpected, especially when presenting on something as factually obvious as vaccines.   Among doctors, this isn’t a debate.  We KNOW the benefits outweigh the risks.  We know it more certainly than we know many other things in medicine.   Vaccines work.  Vaccines are safe.  Vaccines are vital to our communities’ well-being.

“Liar, you’re all just in it for the money”, someone yelled.   I was angry, defensive, and incredulous.  And above it all there was a sense of surrealism, surely this can’t be real?

But sitting in town hall for 5 hours listening to a crowd of passionate parents and advocates beg that they be allowed not to vaccinate their children I had time to work through some of that.  I had time to get past my perspective and reactions.  So I listened.  Prior to speaking (and being identified), I exchanged smiles with the mother nursing her infant to quiet them, with the mother patting her young daughter’s head while she colored quietly, with the two boys a little older than my eldest who after a few hours of sitting were getting antsy.  There were no smiles after I spoke.  But still, I listened.

A young lady, presented to the Board passionately about bodily autonomy, scholastic freedom, and freedom of choice. While I disagree with her stance entirely, I was, in an odd way, proud of this fierce young woman. She was clear and articulate and witty. I wanted to congratulate her on her activism, on her bravery, on questioning authority figures. I wanted to tell her how impressed I was, and how I was sure she was going to be successful in life, a voice for change, a voice for those who might need help finding their own. But that would have been inappropriate and likely unwelcome. And my heart broke a little, that I as a female physician couldn’t offer this mentorship and support, that in this critical space, doctors were neither trusted nor respected.

Another woman pleaded with the Board to find compassion for those gathered, who sought only to protect their young. And I wondered, how do you tell people who are so certain, that the actions we take that they oppose, are in fact borne out of compassion? Compassion for all the children at risk by being unvaccinated? Compassion for bereaved mothers of children now deceased from preventable infectious diseases? Compassion for cancer patients who are already fighting for their lives, that they not be subjected to yet another battle? It would be perceived as paternalistic and demeaning.  My heart broke a little more.

I heard people decry feeling silenced and coerced, being thought of as uneducated or uninformed. Mostly, though, I heard fear. Profound soul-shattering fear. The instinct to protect our young from a perceived threat is deep-seated; this is a fear that doesn’t allow for logic, or rationality.

Suspend your medical training, your knowledge for a moment. Imagine being cornered, feeling that the doctors and nurses were out to hurt your child, that the government was complicit and supporting them, that YOU were the last line of defense for your children from absolute inevitable severe harm. Imagine that for a moment.  Stay in that place.  Become uncomfortable.  In fact, the horror must be untenable.  I was a parent before I was President-Elect of the OMA. I would stand in front of a firing range for my children. My heart breaks entirely.

It’s an easy stance, being firmly on the side of science, insisting that population health supersedes individual choice.  In fact, I salute the Board of Health on taking a leadership stance on this issue.  It’s hard to hold a space of compassion for the “anti-vaxxers”, to remember that behind their hurtful words and upsetting actions, they are simply terrified and angry parents trying to do their best for their children.  But as I walked away from town hall on Monday, my broken heart demanded that I try.

 

 

 

 

 

 

 

Communities Can Play a Role in Physician Recruitment and Retention

Note:  This blog was originally posted by myself on the OMA website.  It’s presented here as for those of you who don’t go to the OMA site.

Earlier this month I was pleased to have an opportunity to speak to municipal leaders from across Ontario at the Association of Municipalities of Ontario (AMO) conference in Ottawa.  I talked about how small and mid-size communities can play a significant role in attracting and retaining doctors.

Family doctors are the gateway to the rest of the health care system, and many communities don’t have enough of them (or specialists).  We’ve all heard about small towns losing one or two doctors in a short period and then scrambling to attract replacements. More doctors where we live means fewer sick days, stronger economic growth, and longer, healthier, happier lives.

What can municipalities do to attract and retain doctors? Start with making succession plans with your local doctors sooner rather than later. You can also encourage them to take on medical residents – ‘trainee doctors’ who need to work under the supervision of an experienced physician. If you give residents an opportunity to live in your community for their education, they just might stay.  This is what happened to me.  I spent two months of my training in small towns, and came to love the lifestyle and the style of practice.  Now I practice in Stayner, which has 4,200 people.

Small and mid-sized communities are some of the best places in the world to live. Community-minded purpose, cheaper real estate and rent, easy access to the great outdoors, and friendly and welcoming people is a big competitive advantage. Twenty-seven years of practice in Stayner, and I still feel the same way.

Once the trainees are in your community, make them feel at home. They’re looking for a community and a lifestyle, and not just a job. Work with local businesses to create a great welcome package, like a complimentary pass to the YMCA, local parks and attractions. Make sure they’re invited to community events. Anything to get this excellent talent feeling at home and feel like they are part of the community. You want them to envision putting down roots.

As the provincial government sets out to transform Ontario’s health-care system and implement Ontario Health Teams, strong local health care has never been more important.  The Ontario Medical Association has been working closely with the Ministry of Health to deliver the best health care possible to every resident in Ontario. To help support these changes, your community needs health care infrastructure. The top-of-mind definition of infrastructure – like sewers and roads – usually heads the list in the planning process. It’s equally important to ensure that health care infrastructure keeps up with future demand – and at limited cost to taxpayers.

Ontario’s Planning Act allows municipalities to require community benefits from developers where their projects exceed local zoning by-law densities. Traditionally, this funding is earmarked for projects like street improvements, playgrounds, daycare spaces, or affordable housing. These are all important, but as communities grow, appropriate commercial space will be needed to welcome and encourage new health care practitioners and facilities. This could be a physician’s clinic, or an office for the new Ontario Health Teams.

While health care is largely a provincial responsibility, the message I wanted to get across in Ottawa is that municipalities can and should play an important role in shaping their own health care future.

During my time at AMO it was interesting to hear about the innovative steps communities have taken to successfully attract and retain doctors. We would love to hear what strategies have worked in your community. Let us know via the OMA social channels.