Category: Politics

 

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Council, governed by outdated parliamentary rules which promote factional disputes, will be replaced by a general assembly that still represents members through section, district and forum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.

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.

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.

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.

 

 

 

 

 

 

 

Disclaimer:  The following blog was written by Dr. Darren Cargill (pictured below).  He asked that I put it up for him.  Dr. Cargill is a palliative care physician from Windsor, Ontario.  Opinions are his and his alone, and do not necessarily reflect my opinions, or those of the Ontario Medical Association.

Recently, a series of articles in the Toronto Star claim that Ontario Premier Doug Ford is looking at “private” options to end hallway medicine.  This was, of course, immediately denied by Health Minister Christine Elliot who stated her government’s ongoing support for public health care.

To support this narrative, the Ontario NDP brought forward a leaked piece of draft legislation called the “Health Systems Efficiency Act”. This draft suggests that all 14 Local Health Integration Networks (LHINs) and many other agencies (Health Quality Ontario, eHealth, etc.) are to be rolled into one big Agency.  NDP Leader Andrea Horwath claims that this draft legislation is a signal that private health care is the real agenda for the Ford government.  Interesting times for health care in Ontario.

In Andre Picard’s book “Matters of Life and Death,” he eloquently outlines the history of Medicare in Canada, warts and all.  I think we can all agree with his comment “Canadians want care that is appropriate, timely, accessible, safe and affordable, from birth to death.”

So here is our story. In 2007, my wife was diagnosed with cancer. She received excellent care here in Windsor as well as at Western in London as part of her journey.  I can honestly say, that she would not be here today if not for that excellent care. I am indebted to our system for saving her.

Getting cancer at 29 is frightening.  When we wanted a second opinion to confirm the diagnosis and ensure that we were receiving the best possible care, we booked an appointment at Karmanos Cancer Centre in Detroit.  A second opinion in Ontario would have taken months. We got our appointment within days across the border. They confirmed that Windsor was giving us fantastic care.

At one point during her treatment, she needed an MRI.  The wait was many months in Ontario.  At first, she was ok to wait but as the days passed, the wait took its toll.  Eventually, we decided to go to Detroit and have the MRI done, with only a few days wait and near instantaneous access to the results.

When we needed help conceiving following chemotherapy, this too was not covered by our public system and we paid out of pocket for that.  We required help from physicians in both Windsor and Detroit. Today we have a son.  And he has a mother.

Neither system alone gave us what we needed. It was both.

We already have private health care in Canada.  Doctors’ offices are privately run businesses that rely on single-payer public funding to operate. We also have private care when we pay out of pocket for drugs, physiotherapy, psychotherapy, fertility treatments, and dental care.  Canadians already spend money out of pocket for health care so the fears around a “two-tiered” system are odd, to say the least. Two-tiered refers to the argument about equity, not public/private, in my humble opinion.

Many will claim I am a physician and had “the means” to avail myself of private care.  But for the record, I was less than 2 years into my career and still had over two hundred thousand dollars in debt from tuition gathering interest every day.  We had to ask family for loans to support us.

For me, the price was worth it.  I would have preferred to have all of our care provided in Canada, but the public system simply could not give us everything we needed.  I believe it was providence that we ended up in Windsor, a short drive away from a world class cancer centre and fertility experts in Detroit.  Ontario gave us most of what we needed and prevented catastrophic financial consequences but privately delivered care in Detroit helped to fill in the gaps.

Why couldn’t I have those options in Canada?

To be clear, I am not suggesting we adopt a US style for-profit system and I am not suggesting we abandon our public system. What I am suggesting is that we have a mature conversation about our system, it’s limitations and whether there is a way to supplement or augment our “good not great” publicly funded, single payer system with private options that could enhance the care we deliver. Can we make our system better through private innovation and efficiencies while preserving all the best parts of public Medicare?

I am asking for a conversation.

As a palliative care physician, I won’t benefit from privatization.  End of life care and symptom management for patients with life-limiting illness will remain publicly funded.  But end of life care does give us a great example of what a good conversation could look like.

In 2015 the Supreme Court of Canada’s Carter decision came down and we were required, as a nation, to address the issue of Medical Assistance In Dying (MAID). Previously, MAID was taboo and “verboten.”  We could not raise it with our patients or even discuss it. But a funny thing happened. Once this prohibition was raised, it got easier to discuss death and dying. Whether or not you support MAID or not, one thing is indisputable.  The conversation has been elevated.

In his book, Picard states “we talk endlessly about sustainability of Medicare but have no idea what we want to sustain.  Our Medicare model is a relic, frozen in time. Tommy Douglas’s role in shaping publicly funded health care is celebrated, mythologized even.  But we conveniently ignore that Medicare was designed to meet the needs of 1950s Canada.”

All on the first page of his chapter on Medicare.I couldn’t agree more.  And while we are at it, let’s stop tilting at wind mills.

I do not pretend to have all the answers.  I just know we need a mature conversation about public AND private health care.  Let’s not shut down the conversation out of fear-mongering and ignorance. To paraphrase former CPSO president David Rouselle: “let’s not repeat the same sterile conservations again.”

Looking through my in box, I see:

• A report from an interventional radiologist, who performed a percutaneous vertebroplasty (injecting a bone in the spine with a form of cement) on a patient of mine with severe back pain.  She now walks without a cane.
• A report from an interventional cardiologist who performed a very difficult cardiac stenting procedure (insertion of tubes in the blood vessels to the heart) on a patient of mine with unstable heart pain – probably saving his life
• A report from an ophthalmologist, who expertly fixed my patients cataracts. She can now see her grandchildren clearly for the first time in years.

I think of colleagues like these (and many others) when I read about how Dr. David Jacobs, a radiologist and former Ontario Medical Association (OMA) Board member, would like to start a separate organization to represent specialists.  Dr. Jacobs is well known in the profession for his actions during what’s become known as the tPSA fiasco of 2016.  The former leadership of the OMA negotiated a deal with the despicable Kathleen Wynne government, but there were many questions about the process.  Dr. Jacobs exposed the situation in the press, and helped to stop a deal that would have effectively destroyed health care in Ontario.  It’s well known that I worked with him to stop this bad deal.  However, I think he’s on the wrong path this time.

I can appreciate how hard it must be for some specialists to feel good about the OMA right now.  On October 21, OMA Council passed an advisory motion recommending that the top three specialties might get cut by up to 6 per cent more (1% per year until 2024) than they have been already.  Most Ontario physicians unilaterally had their gross incomes cut by 7 percent by the desultory Kathleen Wynne.  Some of the higher paid specialties were cut more due to what’s known as targeted cuts.  If the OMA Board agrees to the Council motion, some specialists would be even more angry at the Association.

But the reality is that if Dr. Jacobs is successful in his endeavor, specialists will get eaten alive by government.  Any government.

The best example of split associations is in Quebec.  Specialists and Family Doctors each have their own associations. One can certainly see the appeal of going that route when you read stories about the big “raise” that specialists in Quebec got in 2015.  The “raise” was so large that some doctors actually protested it as being too much (no really) and wanted to give some of it back.

But one has to look at the facts first.  The deal was meant to compensate doctors for the fact that there was NO increase from 2007 to 2015 (fat lot of good having two associations did then).  Now, before the bulk of the “raise” sets in, a new government is in place and plans on eradicating it.  Who do you think can fight against governments more? Two small groups or one large one with more resources than either one?

Additionally, I’m not convinced that most specialists are aware of what the OMA is asking for in arbitration.  The OMA is asking for a repeal of all the cuts (targeted and otherwise), and normative increases (raises).  By contrast the small specialist group seems to only want the cuts repealed.  They have not asked for raises.  Why would specialists want to join a group that is asking for LESS at arbitration than the OMA is?

Here’s where this really hurts the specialists.  If I was the government, I would look at the fact that I was in arbitration with the OMA.  Faced with the possibility of physicians being paid more than I was willing to pay, I would try to divide the OMA.  I would probably send some sort of official to talk to the disgruntled doctors to encourage them on.  See if I could cause dissension in the OMA while I was fighting them in arbitration. If I was able to split the OMA, I would happily start to advertise the high gross billings (while ignoring their overheads) of this group of specialists and then use that to cut their billings even more in the future.  It’s called playing the long game.

Some specialists are understandably upset right now.  But under the current Arbitration process with the OMA, they still have the potential to recoup more of their lost income than this new group suggests.  Council also approved exploring potential dispute resolution mechanisms for relativity in arbitration.  If this can be organized in time, they would have a fair, impartial avenue to address their concerns.  Specialists will not have access to Binding Arbitration if they form a small separate group.  What are the chances that any government would freely offer a valuable bargaining tool like Arbitration to a newly minted organization?

Many doctors are frustrated with the pace of change at the OMA.  As someone who’s been accused (not altogether incorrectly I might add) of being too impatient himself, I understand that.  The OMA has made significant strides in the past year. More is planned.  But to bail out in anger only hurts people in the long run.

I worry that joining this group out of frustration and anger is going to further harm the specialists that I rely on to treat my patients.  They’ve taken a huge beating (as have all of us) the past few years.  The beating has not only been financial, but psychological and emotional as the loathsome Wynne government heaped scorn on doctors at every opportunity.

But in their anger, they are allowing themselves to be played by the government, and I fear they will be much worse off in the long run as a result.

Disclaimer:  As always, just a reminder that while I am President-Elect of the OMA, the opinions in the blog are mine, and not necessarily representative of either the OMA as a whole.  I just like to tell people what I’m thinking.

Changes at the Ministry of Health (MOH)

Interesting change at the MOH.  Nancy Naylor, who was the second in command, has left the Ministry.  She is going over to the Ministry of Education.  I had the opportunity to work (briefly) with Ms. Naylor when I was on the executive of the Section of General and Family Practice.  I found her to be a very knowledgeable person and easy to work with.  I certainly wish her well.

However, as my loyal fans (both of them) know, I don’t particularly believe in co-incidences (Bob Bell suddenly “retired” when the Liberals lost?  Yeah, right).  At the MOH Ms. Naylor was the person the LHINs reported to.  Leaving that role during a transitional period is very curious timing.  Given that Premier Ford has instituted a hiring freeze on bureaucrats, that means that the LHINs don’t currently report to any one other than new Deputy Minister Helen Angus.  Frankly, looking after the LHINs as well as doing everything else the Deputy is required to do is a lot to ask.  Unless (and this is pure speculation on my part) this foreshadows the long hoped for elimination of the bureaucratic quagmire that are known as LHINs.  Be interesting to see how this plays out over the next couple of months.

Changes at the Canadian Medical Association (CMA)

This week, the CMA is holding it’s annual general meeting.  Dr. Gigi Osler takes over as President.  I had the pleasure of meeting her (however briefly) at the OMA Annual General Meeting in April.  Dr. Osler is a remarkable woman with more accomplishments in her pinky finger than I have in my whole body.  That the CMA is going to be led by her this year is unquestionably a benefit for the organization (given all their troubles this past year) and for physicians across the country.  Dr. Osler is an incredibly passionate advocate for physicians health and well being, and we are all lucky to have her speak out on such an important topic.

I do wonder how she is going to handle the internal politics of the CMA.  Based on the interview given by outgoing President Dr. Laurent Marcoux, it really seems to me that the old guard at the CMA (which still populates much of the Board and management) really doesn’t understand just how much they’ve alienated their members.  You would think the uproar created by their flawed “Vision 2020” mandate, not to mention the sale of MD Management, would have made them at least reflect on their path.  Physicians need a national advocacy association that places their interests first.  I hope the CMA recognizes that Dr. Osler’s popularity is because she speaks to that need, and that the old guard doesn’t try to silence her.

More Thoughts on the Strike in Thunder Bay

The strike at the Port Arthur Clinic was finally settled last week, after a bitter, acrimonious period that included a fence being put up, and criminal activity being committed by somebody.

I still worry about what this means long term for the Port Arthur Clinic.  They are all human beings there, and I can’t imagine that it will be easy for them to get back to work. It certainly will take years for the trust to rebuild.  I suspect, sadly, that we haven’t heard the last out of issues coming from this clinic.  I hope that first and foremost, the patients get the care they deserve.

Ontario Medical Association (OMA) Becoming More Outspoken

It’s been a couple of turbulent years at the OMA.  However, it’s nice to see that the leaders of Association speaking out more and more on physicians issues.  It started last year when Dr. Shawn Whatley was President and he advocated strongly for physicians first.  Through his many blogs (which are required reading for anyone interested in medical politics) and his multiple TV and radio appearances, he really got the ball rolling.   His simple mantra that you can’t improve health care by disparaging physicians, while self evident, really struck a chord and needed to be said.

This year of course, we have the incredible Dr. Nadia Alam.  Another ridiculously accomplished young physician, she has moved quickly on her belief that the OMA must defend physicians when they are attacked, and defend patients when their care is compromised.  This was most recently seen in her quick reaction to the strike in Thunder  Bay.  Whether in the news, or her personal blogs, she has repeatedly been speaking out on issues where physicians voices are compromised.

While there is still much more to be done at the OMA, it’s refreshing to see that the organization is speaking out on areas like this.  It means I have huge shoes to fill next year, but I can honestly say I’ve been inspired by the actions of the last two Presidents.