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Ontario’s Heading For Another Family Doctor Shortage

This is the follow up blog to my last one, originally published in the Huffington Post on June 13, 2017. Reprinted here so that I can keep track of my old blogs, and also to once again point out how warnings of a crisis in Family Medicine were ignored for years.

The Barer-Stoddart report. Ask any physician of a certain age and the immediate reaction is likely to be disparaging. Written in 1991, it purported to help chart the course of the physician workforce into the 21st century. 

While it’s true that much of the report was ignored by the Ontario government of Bob “Super Elite” Rae, it’s still widely remembered for suggesting that the number of physicians in Ontario needed to be cut by 10 per cent. To accomplish this, medical school enrollment was slashed in the early 1990s.

Given that the population of Ontario continued to grow and age, the result was completely predictable. A massive doctor shortage (particularly in family medicine) hit the province at the end of the decade. It has taken the last 15 years to come close to correcting that. We’re not there yet (we still have fewer doctors per capita than Mongolia), but we were improving.

Alas, Ontario Health Minister “Unilateral Eric” Hoskins and Deputy Health Minister Bob Bellwere unable to remember the old saying, “Those who cannot remember the past are condemned to repeat it.”

Former Health Minister Dr. Eric Hoskins

Last week I blogged about how Hoskins and Bell need to support family medicine. Because they are not doing so, many physicians who graduate from family medicine residencies are not starting comprehensive family practices. Instead, they are doing things like hospitalist work, sports medicine and even medical marijuana clinics.

However, the situation is even worse than I thought. It was pointed out to me after my blog was published that the number of medical students applying to family medicine programs has dropped considerably this year. In Canada, to become a practicing physician, you first have to graduate from medical school, then do a residency (essentially a training program) in the specialty of your choice. To choose a residency, you apply to CARMs — which is a Canada-wide program that matches medical school graduates to the residency of their choice.

This year’s CARMs match shows some alarming results for family medicine in Ontario. Ideally, we should have 45 to 50 per cent of all graduates from medical school apply to family medicine for a sustainable workforce. However, only the Northern Ontario School of Medicine achieved that goal. While it’s a great school, it’s still the smallest of Ontario’s six medical schools.

By comparison, only 24 per cent of graduates of University of Toronto applied to family medicine, 27 per cent of Queen’s graduates, 32 per cent of Ottawa’s graduates, etc. Multiple studies show that comprehensive family medicine is responsible for decreased health-care costs, more efficient utilization of the health system, better patient outcomesand decreased hospitalizations. It is essential for a sustainable health-care system to have a strong family medicine component. The fact that so few medical school graduates chose family medicine, on top of the fact that recent graduates are not opening practices, should be setting off alarm bells.

So, why is this happening? First and foremost, it’s because Hoskins and Bell have refused to support family medicine. They have talked loudly about how they want to cut payments to higher paying specialties so that they could fund family medicine. Hoskins even went to the trouble of doctoring (pun intended) a chart to accuse specialists of overbilling. 

(Seriously, see the picture in this article. Notice how he made the pie chart on the right larger — the whole circle, not just the wedge showing percentage of billings. Makes the red area look LARGER than it really is, and makes the specialists look they are billing disproportionately more than they are.)

Unfortunately, while Hoskins and Bell were saying this in public, what they were actually doing is cutting family physicians. They unilaterally cut the number of physicians who could apply to the capitation (salary plus performance bonus) models of funding that I mentioned last week. This is the preferred method for paying physicians for newer graduates, and also for health care bureaucrats who like a predictable budget. Additionally, they cut a number of the performance bonuses family physicians got for looking after complex patients.

Medical students are not dumb. They saw all of this going on, and realized that family practice was no longer preferred by Hoskins and Bell. So they made career choices accordingly.

Currently, the Hoskins/Bell legacy is not a pretty one. It’s one of internecine disputes with doctors, laid-off nurses, hospital deficits, patients in stretchers for days and egregious wait times. At least with family medicine, they have an opportunity to begin to correct this mess by once again allowing new physicians to enter the capitation model, and restoring the various performance bonuses.

Failure to do so will mean that many years from now, as patients struggle to find a family physician, Hoskins and Bell will be remembered with the same disparaging legacy as Barer-Stoddart.

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Hoskins and Bell Need to Support Family Medicine

The following is a reprint of an article that I wrote for the Huffington Post on June 5, 2017. Re-posting here so that we can see how the seeds of declining family physicians was planted by Drs. Eric Hoskins and Bob Bell, and also so that I can refer to it in the future if needed.

For the past 23 years, it’s been my pleasure to be a preceptor with the Rural Ontario Medical Program based out of Collingwood. As a preceptor, I have had the honour of supervising a wide variety of Medical Trainees, from first year Medical Students, all the way up to those in their last year of Residency. 

I often find I learn as much from them as they learn from me (it’s good to be questioned by students about why you do things the way you do). I clearly have some experience on my side, and they have more recent book knowledge. It’s a great combination for patient care.

Unfortunately, I can see that we are once again heading for the same situation as the late 1990s/early 2000s, when many medical trainees stopped going into comprehensive family medicine. The reasons then were due to increased workload, better opportunities in other specialties and an extremely poor relationship with the government of the day. 

At one point, only about 25% of graduates from medical school applied to Family Medicine Residencies. To suggest that there was a crisis in family medicine would be dramatically understating the issue.

However, the Conservative government of Mike Harris finally realized you need to co-operate with doctors if you want to improve patient care. In 2000, Health Minister Elizabeth Witmer rolled out something called Primary Care Reform (PCR) in co-operation with the Ontario Medical Association (OMA). This, over the next few years, led to a revitalization of Family Medicine, and now, close to 40% of medical school graduates are once again choosing Family Medicine as their specialty. 

While not the sole part of the PCR, a major component was a new model of paying physicians known as capitation. Capitation is essentially salary plus performance bonuses. Family Physicians would be paid a certain monthly rate to look after their patients, regardless of how often they saw them. They get bonuses based on how many complex (eg. Diabetic) medical cases they take on. This was in stark contrast to the old system known as Fee For Service (FFS) where physicians were essentially paid piecemeal (only got paid when they saw a patient).

The capitation based models were extremely popular with both Family Physicians and government. For Family Physicians, it allowed them to spend the time needed with patients during just one visit, instead of requiring multiple visits. For the government, it provided a predictable funding envelope. I appreciate this will come as a surprise to a couple of the frequent critics of my articles (in the comments), who have long implied that I was critical of Health Minister “Unilateral Eric” Hoskins because I was allegedly supporting the FFS model, but I actually have been in a capitated model since 2004.

UHN President and CEO Bob Bell

Drs. Bob Bell (left) and Eric Hoskins

Did PCR work? In 2001, the population of Ontario was 11.4 million, and almost 3 million people didn’t have a family doctor. In 2016, the population of Ontario was 13.9 million, and only 800,000 did not have a family doctor. So over 4.5 MILLION people got a family doctor.

Then along came the hapless “Unilateral Eric”, and his widely disliked sidekick, Deputy Minister Bob Bell. “Unilateral Eric” likes to claim that he himself is family doctor. The reality is that he has NEVER provided the cradle to grave care that comprehensive family doctors in Ontario do on an ongoing basis. He does work a day a month at a walk in clinic, and I understand he donates that income to charity – which is good of him, but it’s hardly the same as what comprehensive family doctors do. 

Bob Bell for his part, likes to boast about how he used to be a family doctor back in the 1970s, but he seems to be unable to grasp that family medicine might have evolved since then.

Acting with the same level of competence as Tweedle Dee and Tweedle Dum, the infelicitous duo of Hoskins and Bell unilaterally cut the number of family physicians who could apply to capitated funding models. Again, this is likely a surprise to a couple of the critics of my columns, who have long been demanding that physicians go on salary. Surprise, it was Hoskins and Bell who unilaterally stopped the salary style models, not the OMA. They also unilaterally cut some of the performance bonuses (for things like diabetic care, medical education and so on).

The result was clearly predictable to anyone who understands Family Medicine in the 2010s. Over the past three years newer graduates from Family Medicine programs are avoiding comprehensive care. Many of my trainees are choosing to work solely in areas like emergency, anaesthesia, sports medicine or others. And while there is a need for doctors in all fields, the reality is that it’s comprehensive Family Medicine that leads to health system stability. 

It’s comprehensive Family Medicine that reduces hospitalizations. It’s comprehensive Family Medicine that when supported properly, reduces costs of health care.

In response to this, the dolorous duo of Hoskins and Bell unleashed something called the New Graduate Entry Program (NGEP) to provide new family medicine graduates with what they claimed was a capitated funding model. Alas they attached so many conditions including a morass of bureaucratic oversight that I understand only two new graduates have taken them up on this offer.

Hoskins and Bell have left a legacy of a crumbling health care system with their arroganceand unilateral cuts. 

However, they still have the ability, and opportunity to begin to correct one of their most egregious mistakes. A new crop of Family Medicine Residents will graduate on July 1. Hoskins and Bell can unilaterally reverse the cuts to the capitated models and performance bonuses. No one from the OMA will complain.

It’s time for them to recognize the important role of comprehensive Family Physicians, and support that with actions, not just words.

I Pray The Experts Are Wrong, Because Ontario Can’t Handle a Surge in Flu Cases

Note: this article initially was published in the Huffington Post in November of 2017, and is being reproduced on my personal blog site. The purpose is to outline that our system isn’t collapsing because of Covid. It’s collapsing because despite multiple warnings from people like myself that our system was NOT EVER prepared to handle an unexpected event. My thanks to Dr. Adam Stewart for reminding me I wrote this.

We know the hospital system has no surge capacity. If you are already at 110 per cent, where’s the room to surge?

This year, Australia has suffered through one of its worst flu seasons in history. There were 166,000 cases of the flu through September (their flu season lasts through October) which was up from 91,000 for all of 2016. Over 300 deaths were attributed to the flu in Australia this year, including many people who were apparently healthy.

Tragic as this was in Australia, is this a concern for Canada? Unfortunately, the answer is yes. While the influenza virus is famously described as “predictably unpredictable,” leading flu experts have noted that Australia (where the flu season typically starts first) is often a predictor of what happens in North America. It’s usually the same strain of influenza that crosses the ocean to our continent each year.

Now, there are something like a gazillion strains of influenza. I won’t bore you with molecular biology, but keep in mind that one particular family of the flu virus, H3N2, is a bad one. What’s worse, there are multiple sub-types of H3N2, which makes immunization a real challenge. You see, each year leading experts make the best possible guess at predicting which flu strain is going to affect the public and cater the flu shot to that strain. Last year, for example, they were spectacularly successful and we had a relatively mild season.

This year, Australia was hit by the H3N2 family, and while their vaccine DID have protection for H3N2, it still appeared to be a mismatch. Most likely this was because the H3N2 virus mutated and formed another sub-type that was not as effectively covered by the vaccine.

Which flu vaccine are we getting in Canada? The same one the Australians got. Which strain of flu seems to be coming to Canada? According to Health Canada, as of last week, the majority of detections are H3N2. So the experts who were expressing concern are unfortunately being proven correct.

The flu, of course, generally affects the elderly, the very young and the patients with chronic medical conditions (heart disease, kidney disease, cancer, etc.), or those with compromised immune systems (e.g. patients with diabetes). What’s worse, it weakens patients considerably and makes them prone to a secondary infection (usually a pneumonia on top of the flu) which may ultimately lead to their death or prolonged sickness.

The worry that Ontario physicians have with this situation is twofold. First and foremost, we are concerned for our patient’s well being. Despite many attempts to get EVERYONE vaccinated, the legion of anti-vaccination followers (led by leading virologist/immunologist/brain surgeon Jenny McCarthy) seems to have increased. Even a partially effective vaccine is better than none, and so it behooves everyone to get their shots.

Secondly, physicians already know that due to the woeful mismanagement of the Ontario health-care system by Premier Kathleen Wynne and her hapless Health Minister Eric Hoskins, Ontario hospitals simply don’t have the resources to cope with a surge of patients. This was proven in dramatic fashion this past summer when a shortage of beds in neonatal intensive care units played out. The short version is there was a strong need for an increased number of beds, and these beds weren’t planned for. Health Ministry spokesperson David Jensen tried to spin this in the media as a one-off event, referring to it as an “unusual surge.”

However, this is just ridiculous. All health systems NEED to plan for unexpected circumstances. That’s why best practice evidence shows that hospitals should, on average, run at 85 to 90 per cent occupancy. This allows planning for unexpected events (that are becoming more and more common).

Under Wynne and Hoskins’ watch, Ontario hospitals now routinely run at over 100 per cent capacity (many are between 110 to 120 per cent). This essentially means that if you have a 100-bed hospital, there will ALWAYS be between 10 to 20 people in the emergency room, lying on a stretcher, waiting for a bed in an inpatient unit. And that’s WITHOUT any unexpected surge.

What happens this year if the flu season is as bad as experts suggest it may be? Patients who are already weakened from other illnesses will, of course, go to the hospital to treat the dehydration, muscle aches, vomiting, secondary infections and so on that all come with the flu. But if they need to be admitted, where will they go? Will they wind up in “unconventional spaces?” (FYI: “unconventional spaces” are spots like storage rooms.) Is this what we can expect from our vaunted health-care system — to lie for days in a hallway with no dignity? We know the hospital system has no surge capacity. If you are already at 110 per cent, where’s the room to surge?

So, I ask everyone to do a couple of things. First, get your flu shot (some protection is better than none). Second, if you are unfortunate enough to need hospital care, please remember that the doctors and nurses in the emergency department are going all out with the resources they have (they just don’t have the space to provide adequate care). Third, if you are upset about your situation in the hospital, please contact Premier Kathleen Wynne (there’s an easy link here), and tell her what you think of her management of the health-care system. (We doctors have tried for the past three years, but she just doesn’t seem to want to listen to us.)

Here’s praying that the experts are wrong about this year.

Patrick Brown is the Right Choice to Lead Conservatives

Patrick Brown
Patrick Brown and his wife, Genevieve Gualtieri

Most of my regular followers know that I am a long time Conservative. Heck, I was one of the Youth for Mulroney back in the early 1980s. Like all members of the Party, I’ve been saddened by the inability to win a national election since Stephen Harper lost in 2015. Canada would have been MUCH better off if he was Prime Minister during the Covid Pandemic. Playing to the media for photo-ops is one thing, but in times of crisis, we needed a leader with intellect, and Harper has that in spades.

Also like most members of the Party, I need to weigh who to vote for in the current leadership contest. Both the party and Canada are at a cross road. It’s not just a potential 10 years out of power. It’s about a current environment where unfortunately, Canada seems to have become a more divisive country.

Those of us who are on Social Media have seen it first hand (there is a reason looking at your Twitter feed is often referred to as “doom scrolling”). But there is also evidence of division elsewhere.

We see people who feel that they can assault store workers for enforcing mask mandates. Whether in Calgary, Peterborough, or elsewhere, this kind of behaviour speaks to a corroding of Canadian’s reputation as a kind people.

There’s also been a seeming uptick in racial violence in Canada. Whether it’s the rise in Islamaphobic attacks on Muslim women in Edmonton and elsewhere, or the increase in hate crimes against Canadians of Asian descent, or the continued inability to squash anti-semitism, or ongoing racism against our Indigenous people or more, Canada seems to be in a darker place than I can recall in my now half century in this country.

Against this backdrop, what we really need is a Prime Minister who can inspire all Canadians to believe that they belong to and are part of Canada. A Prime Minister who can at least be seen as someone who works to unite Canadians. A Prime Minister who truly believes that even if we have political differences, we all matter.

Instead, we’re stuck with Justin Trudeau.

A PM who preached feminism, but summarily dismissed two strong independent women for having the gall to disagree with him. As an aside, just how much better would our Covid19 response have been had Dr. Jane Philpott, now Dean of Queen’s University Faculty of Health Sciences, been in cabinet?

A PM who preached reconciliation with the Indigenous people, but still hasn’t delivered on clean drinking water on reserves. To show you just how much he thinks of the Indigenous, he decided to go on vacation during National Truth and Reconciliation Day.

And finally, yes, a PM who decided to deride and debase those who were involved in the “Freedom Convoy”. Yes, they went too far and should have gone home sooner (I’ve written that before). But the reality is that it was only a small minority of that convoy that were incorrigible racists. A real PM would have met with the group even though they disagreed with his views. It would have shown he listened to Canadians from all sides of the political spectrum. But instead, he chose to be a divisive force, instead of a unifying one.

Which brings me back to the Conservative leadership race. Conservatives face a choice not just of leaders, but of the type of party they want to build. Do we want a party that divides Canadians and marginalizes some groups but from the other end of the political spectrum? Basically a conservative version of Trudeau that will insult and deride those with progressive/liberal views.

Or do we want a truly inclusive conservative party? One that is open to all people. A party based on the principal of sound fiscal management and fair treatment for each and every single Canadian, regardless of background? Even if we have some differences of opinion on how to get there.

Of the current main candidates it strikes me that Pierre Poilievre is best suited to being an “attack dog”. No shame in that, every party needs one. Remember Sheila Copps for the Liberals back in the day? (Google her young ones). But being a good attack dog doesn’t mean you can lead a country.

Leslyn Lewis is clearly a brilliant lawyer but too inexperienced to be PM.

Jean Charest would be a fine leader and I would vote for him if he won. But the reality is that despite being from Quebec, where the party needs to win seats, he carries a lot of baggage as a career politician. This can hamper an election campaign.

This is why to my mind, Patrick Brown is the best choice for leader. He has worked hard to build relationships with many different communities in Canada. He is mayor of an incredibly diverse city (Brampton) and reached out many different minority groups. He’s realized that in order to build a better Canada, one must be able to sell a conservative vision to minority groups that historically have voted Liberal.

The best way to do that is to talk to them and engage them (which he’s done). And in so doing, surprise, surprise, find out that many of these groups value hard work, fair (but not excess) taxes, and fiscal responsibility, i.e. bread and butter conservative values.

For the sake of all Canadians and our children, the Conservatives need to win the next general election. The best way to do that is with a leader who understands the changing demographics of Canada, but also understands that at heart, Canadians are fiscally responsible, kind, and believe everyone matters. That leader is Patrick Brown.

I urge you to joint the Patrick Brown campaign by clicking below.

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It’s Time to Open Up Nursing Home Capacity

Recently, I posted what I referred to as a controversial tweet about the need to open up nursing home beds that had been closed during the seemingly never ending Covid pandemic.

While there was not much “controversy” in twitter feed as a result of this, it did lead to some questions being asked during an interview I gave for CTV News.

While I certainly appreciate the professional nature of the reporter (the always adept Kraig Krause), the reality is that 30 second blurb on this topic, in an interview about all things COVID, can’t really do it justice. So let’s delve into this deeper.

It’s no secret that Ontario’s Nursing Homes were hit hard by the Covid pandemic. One nursing home in my region, Roberta Place in Barrie, was ravaged badly by the disease. I still grieve for all of the residents and families there, including those who survived as they likely continue to suffer some of the after effects of what transpired.

In the wake of these and other such stories, the Ontario government quite correctly limited the number of residents in ward beds at nursing homes. Many of Ontario’s nursing homes are very old buildings. The nursing home I’m honoured to be a medical director for has great ownership (private as it happens) and great staff, but the building itself if 52 years old and would not meet newer, more modern standards for nursing homes.

When my nursing home was built, having a ward bed (four residents to a room) was thought to be reasonable. Given that Covid is airborne (like most other respiratory illnesses!) the COVID19 Directive #3 (linked above) for nursing homes limited the number of residents to two per room. This made perfect medical sense at the time, and I certainly supported it then.

The reality however, is that health care is not limited to a single disease. We do have Covid of course, but we have a whole lot of other illnesses that we need to deal with. The Ontario Medical Association has estimated that a minimum of 16 million visits or procedures have been delayed as a result of the pandemic. We can’t keep delaying these. We need to address all the other health care issues that Ontarian’s have, and not just maintain sole focus on Covid.

Right now, I personally have two patients who are in hospital waiting for a nursing home bed. They are not acutely ill. They do not need aggressive medical treatment. They need a nursing home. But they can’t get one because of the massive shortage of nursing home beds. And while I strongly applaud the government for planning to build more beds, they won’t be here for 4-5 years.

At the nursing home I work at, normally 60 patients could be housed, but it’s now limited to 45 because of the rules implemented during the pandemic. I imagine it’s one of many nursing homes that has been limited. While opening up those closed beds (at all the homes) likely won’t be enough, it will help alleviate the stress on hospitals. This is particularly important given (as I write this) no one knows how bad the on coming Omicron wave will be.

But wait – are we not risking increased covid infections in the nursing homes by doing this? We would be increasing, for lack of a better phrase, population density in these homes. The answer is not as straightforward as one would think.

First we now know that three doses of the Covid19 vaccine provides the maximum amount of protection. Just about every resident of a nursing home has had three doses – as have staff. There will never, ever, ever be a vaccine (for any disease) that is 100% effective. But that fact that our most vulnerable patients have had three doses is incredibly reassuring.

Second, we would have to ensure that nursing homes have the funds to put in proper air purifiers (with Hepa Filters) in their facilities. I’m not asking for a complete re-vamp of the HVAC systems (that will take too long). But even small portable air purifiers will make a difference.

Third, we would need to ensure a rapid swab and immunization policy for staff and visitors of nursing homes to further reduce the risk of Covid entering a facility. Just tossing it out there but how about all staff get swabbed once a week regardless of vaccine status, and visitors twice a week?

Fourth, as one of the smartest people I know put it, a bed is just a piece of furniture. We have to ensure that the homes who are short on staff, now have the ability to hire extra staff to take care of the residents in these beds.

The health care system is a behemoth. It is also interdependent on all of its various parts working together. A shortage of nursing home beds, means more people in hospital waiting for nursing homes, which reduces the hospitals ability to provide acute care which leads to further backlogs and delays in medically necessary treatments.

We cannot make nursing homes 100% safe (we can’t make anything 100% safe). But re-opening currently closed nursing home beds in the safest possible manner, will be a small step in the right direction. It will also provide the hospitals with a little bit of extra capacity, should Omicron stress the system more.

“Clients”: an Offensive, Dehumanizing Term in Health Care

Over the past 15 years, one of the most troubling trends in health care, has been the desire by health care bureaucrats, to start using the term “clients” instead of patients when referring to people who are in need of health care.

Proponents of the term (mostly administrators and managers who probably have never actually provided front line care) make all sorts of pompous, highly exaggerated claims about what will happen if we all start saying “clients.” Magically, people will feel empowered, autonomy will be promoted, and self-determination will suddenly be granted in the treatment planning and recovery process.

Not only that but social, physical, cultural, spiritual, environmental, medical and psychological needs will suddenly be taken care of in health care, because of course, doctors and nurses completely ignore all of this right now.

Reading through documents that promote the use of the term client is like reading a thesaurus of health care buzz phrases. “Shared decision making.” “Partnerships.””Declaration of Values.””Achievement of targets set out in the quality improvement plan.””Patient Experience.” (I note the irony in the fact that they didn’t use the term client experience). All this and much more, thrown randomly and in rapid fire succession at the poor reader, futilely hoping that something will resonate.

What poppycock.

Here’s the thing. The term patient has been around for hundreds (if not thousands) of years. While the bland dictionary definition is “a person who is under medical care or treatment”, the reality is the word has its origins thousands of years ago in Latin (patiens). It has a deep meaning dating back to the days of Hippocrates and denotes a special and honourable bond between doctors and nurses, and those that they serve.

Note my last sentence. “…those that they serve.” The word patient by its historical meaning clearly denotes a deep obligation on those of us who provide health care. The word patient compels us to heed our patients needs, their wants and their desires. It is we who serve them, not the other way around.

Does this always happen? Of course not. There are cases of doctors (and nurses) who have abused the privilege we have of looking after patients. These situations are offensive and diminish the rest of us, and are rightfully and appropriately dealt with by the regulatory bodies.

But here’s the thing. Using the phrase client won’t change any of that. Client is defined as “a customer, anyone under the patronage of another; a dependent.” Client, in its literal definition, suggests a hierarchical, dare I say even patriarchal, relationship that bureaucrats claim to oppose.

Why then is there a persistent desire to try and force this phrase on physicians and nurses? My two Canadian cents (2.44 cents American) is that this is likely driven unconsciously by the fact that many bureaucrats are jealous of the relationships doctors and nurses have with their patients. They won’t admit it, heck, they are probably unaware of it, but my strong suspicion is that the relationship we have with our patients is something bureaucrats fear.

One thing I’ve come to appreciate about bureaucracy in general is that it doesn’t actually care as much about cost savings, efficiency, or even patient experience. What matters most is predictability and control. Doesn’t matter if the budget is going to be three times more than last year, so long as bureaucrats know in advance that it will be that. Doesn’t matter if hospitalization rates go up, so long as, you guessed it, bureaucrats know about it ahead of time.

The reality of health care in Canada is physicians threaten predictability and control. Supposing a patient is admitted to hospital with a pneumonia. Some consultant from Dogbert Inc. will tell me that based on age and co-morbidities that person should spend 3.4 days in hospital. But what if that person lives alone? What if home care is stretched and can’t provide a daily visit on discharge? Well, then the physician will of course, keep the patient in hospital for an extra day or two (because we serve the patients). But there goes the plan the bureaucrat had put forth for the patient. The carefully laid out discharge prediction now has to be unexpectedly revised. The horror!

This is where the term client becomes really offensive, dehumanizing and degrading. When one has a client, they are essentially a commodity. Extraneous factors (likely living alone with no family support) have no meaning. They become a widget that actually has to meet uniform standards (out of hospital in 3.4 days!) or else.

This is why it offends me so when I see health care agencies use this term. Public Health units use it a lot, mental health services are using it and even the last referral form I filled out for Hospital for Sick Children used that phrase.

Shame on all of them.

Words matter. Patient is an honourable phrase, steeped in history and tradition. While ongoing emphasis and education needs to be placed on a patient’s right to autonomy and input into their care needs, renouncing a principled title like patient for a consumerist phrase like client is not the answer. We do need to do better to recognize patients rights, but we need to do it by better realizing the distinguished meaning of the word patient, and not by cowardly giving into bureaucrats who subconsciously want to diminish and degrade the sacred bond we have with those we care for.

And if you don’t believe that other front line physicians feel the same way, see the spontaneous applause I got when broaching this during my inauguration speech two years ago:

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.

Open Letter to Alberta Ophthalmologists

Dear Alberta Ophthalmologist,

I don’t practice in Alberta, and I certainly don’t know all the ins and outs of the Alberta Medical Association (AMA). But I, like every other physician in Canada, am horrified by what’s going on in your province. Your government has torn up a previously agreed to Master Agreement, and despite the attempts by the AMA to fairly negotiate with the government, your association has been ignored, insulted and treated with the most disrespect I have ever seen from a government, and I lived through the Eric Hoskins/Bob Bell years in Ontario!! That physicians are leaving work in your province is absolutely no surprise, and that patients will be the inevitable losers in all this, is entirely predictable.

However, I read with extreme concern when I read about the Eye Physicians and Surgeons Association of Alberta (EPSAA) offering to separate from the AMA and negotiate separately with the government. Sadly, I believe that whatever the internal political reasons behind this may be (let me take a stab in the dark and suggest it has to do with fee relativity and how you feel you are represented on that front), EPSAA is going to find itself played by the government, and you will all suffer after.

You see all of this mirrors exactly what Ontario went through a couple of years ago. We ourselves had something similar happen with the Ontario Specialists Association (OSA). They felt frustrated with the Ontario Medical Association (OMA) for reasons that are likely similar to yours. They thought, as EPSAA clearly does, that they would be better off negotiating separately with the government.

I warned the specialists that they were being played. In my blog, you’ll see I pointed out that in dealing with any militant government, they will use a split in the profession to divide and conquer, and that all physicians would lose out if they tried this.

The response from the Chair of the OSA, Dr. David Jacobs was to suggest that I was wrong in my concerns, particularly about our own Binding Arbitration Framework:

Full disclosure, I happen to like Dr. Jacobs. He’s passionate, smart, opinionated and when push came to shove, really helped the profession more than people give him credit for by publicly exposing the flawed 2016 Tentative Physician Services Agreement.

Despite my warning, he and the OSA persevered on their path however, and held a poll at the end of November, 2018 that suggested that up to 8 specialties wanted to separate from the OMA. And what was the first thing the government did in response to this? They of course, took away the Binding Arbitration Framework for EVERY PHYSICIAN in Ontario. It didn’t even take them two weeks to do that.

Now I would like to think I have a reputation for being very pro physician’s rights. Frankly, I hope to build on that more and convince those of you who may not feel that way that I am pro physician. But to be honest, I didn’t actually blame the Ontario government for trying to take away Arbitration. The reality is that when you are in a tough, difficult negotiation, you always look for weakness in the other side. The government sensed weakness, and so acted on it. Just like the Alberta government will on this move.

Thankfully however, the broader OMA as a whole immediately started a massive advocacy campaign that did result in the government realizing that the profession was maybe not as divided as they had hoped, and arbitration was returned. But the whole mess delayed the hearings that were in progress by a couple of months, and the effects of the delay were clearly felt in the shortened timelines for implementing the eventual Arbitration award.

I also need to point out that your current health minister, Tyler Shandro, is a……..um…….interesting piece of work. I seriously believed that I would never see a health minister as bad as Eric Hoskins from Ontario, ever. But while Hoskins was all kinds of awful and incompetent, at least he never went to a physicians house to berate them, causing that physician to fear for his families safety. Nor did Hoskins ever use his authority to access confidential information on physicians to call them.

Do you really think that Shandro will deal fairly with ophthalmologists, just because you propose to separate from the AMA?

I understand that you are unhappy with the AMA. I certainly spoke to many specialists (and family physicians!) who were unhappy with the OMA. But I guarantee you right now, that if you take this step, and fail to learn from the lessons in Ontario, you will be worse off than before.

The best way to fight a militant, un-co-operative government that seeks to vilify you is to stick together with your colleagues. You may not like what some of them say or do, but I guarantee you that you will be better off with them, rather than trying to do it against politicians and health care bureaucrats who have shown they don’t really care about you. To those politicians and bureaucrats, you are not partners (no matter what they say), you are simply tools and pawns to be used to promote an overall agenda.

I hope you don’t learn that lesson the hard way, like we did in Ontario.

Yours truly,

An Old Country Doctor…….

The Facts About Vaccines

Note:  The following blog was published yesterday on the Ontario Medical Association website.  It’s being reproduced here for those of you who don’t go to their site.

Labour Day has come and gone. The kids are back at school (Woo Hoo!). This seems like the right time to talk about vaccines. For children. For adults. Vaccines protect us all.

Most vaccines come in the form of needles. A few are administered orally or nasally. They protect people against certain diseases and infections. Many of the diseases they prevent are extremely serious, and extremely contagious. It only makes sense that we should all protect ourselves, and at the same time protect others. For children here in Ontario to attend school, they must be immunized against several infectious diseases.

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Not everyone is comfortable with vaccination. Some people make claims about vaccines that are simply not true. Others hear those claims, and become afraid. They refuse to have their children or themselves vaccinated. This is dangerous, for them and for others. Which is why, I would like to present the facts about vaccines.

Fact – Vaccines are safe
It is true that vaccines can cause some side effects, such as headache, mild fever or muscle aches, but for the most part they are minor and quickly go away. You are much, much more likely to become seriously ill from a vaccine-preventable disease than from a vaccine, and the benefits of protecting yourself and those around you far outweigh any potential risks and side effects from vaccines.

Fact – Vaccines do not cause autism
There was one study, more than 20 years ago, that suggested vaccines cause autism. It has since been thoroughly discredited. The author has PERMANENTLY lost his licence to practice medicine. There is not a single piece of evidence linking vaccination and autism.

Fact – Vaccines do not give you the disease they are supposed to protect against
Some (not all) vaccines do contain live versions of the germ that causes the disease, but the germ has been so weakened that it poses no danger for anyone with a healthy immune system. And these vaccines are not administered to people whose immune systems are not healthy.

Fact – It is perfectly safe to receive multiple vaccines at the same time
Your immune system is constantly handling exposure to many things at once. Multiple vaccines do not cause problems for the immune system, and getting several vaccines at once means fewer trips to the doctor for you.

Fact – Vaccines are not only for kids
You are never too old to catch a disease, and you are never too old to get vaccinated.

Fact – If everyone stopped getting vaccinated, rare diseases today such as polio and measles would come back quickly
Polio and measles have been made extremely rare because of vaccination. Let’s keep it that way. If we get vaccinated, and our children get vaccinated, we might even wipe these diseases off the face of the earth.

Fact – Vaccination helps everybody
When the majority of a population is vaccinated, there’s little opportunity for an outbreak. This is called “herd immunity”: the entire population is more protected, including infants too young to be vaccinated and those with weakened immune systems like cancer patients. It is important that those who can be vaccinated get vaccinated to help keep everyone healthy.

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For physicians like me, vaccination really does fall into the ‘no-brainer’ category. Doctors would always rather help their patients avoid a disease than help them recover from it. Which is why the fact that there is any disagreement at all about the safety and importance of vaccines is such a frustration. Hopefully, I’ve been able to help.  Please spread the word. Billions of people around the world, have been protected through vaccination. But that’s not good enough.  We want to protect more.

If you have any concerns about vaccinations please speak with your doctor. There is no substitute for your doctor. Your doctor has the expertise and evidence to help you understand why vaccinations are critical, and what the risks are of not vaccinating your children.

Ontario Health Transformation Needs Strong IT to Succeed

Ontario has recently embarked on what has been described as the biggest transformation in health care since Medicare.  Central to this transformation are the development of two new organizations.

The first is Ontario Health.  Ontario Health amalgamates numerous separate agencies (all 14 LHINs, Cancer Care Ontario, eHealth, etc.) into one large corporation.  The goal is clearly to reduce the duplicate back end administrative costs (separate payrolls, HR departments, workplace policy and procedures and so on) and create an integrated agency with seamless and consistent policies.  As someone who was a fierce critic of the previous LHINs, I can’t help but be pleased at this move.  (It was also recommendation 3 I made to then Premier Kathleen Wynne on how to fix health care).

The second move is to create Ontario Health Teams (OHTs).  In broad terms the goal of the OHTs is to ensure that doctors, hospitals, home and community providers work together as one co-ordinated team to help patients.  The OHTs stated goal is to integrate care around the patient.

The concept of OHTs is certainly a good one.  There is plenty of evidence that suggests integrated care is good for patients.  Jenny Grant (from McKinsey and Company) wrote about the benefits of integrated care (particularly for patients with chronic disease) and pointed out:

  • Sweden reduced the need for hospital beds after introducing this model
  • Sweden also reduced the number of “delayed discharges”
  • A reduction in hospital admissions AND lowered patient costs for patients in Geisinger’s Medical Home Program
  • A 79% reduction in wait times for social care assessments after Tobray Care Trust introduced the model

Given numbers like that, it’s no wonder that the government is exploring this model for Ontario.  Physicians also support the concept of integrated care because at the end of the day, we want what’s best for our patients.  We will always support policies that provide good health care (and we will always criticize polices that disadvantage patients).

What’s needed however is to turn that concept into a truly functioning entity.  These models be voluntary, physician led and primary care based.  In order to do that, there are two absolute musts that the OHTs require to be successful.

First, the OHTs must have strong physician leadership, particularly at the governance level.  Greg Scrine from Lumeris said it best regarding the American version of integrated care (the Accountable Care Organization):

“Physician engagement is the key to the success of an ACO, and consequently the efforts of setting up an ACO need to be physician driven to achieve the desired results.”

In Ontario, this does not seem to be a problem.  The Ontario Medical Association (OMA) has held several town halls on what OHTs are, and over 800 physicians participated.  There is keen interest in this model from leading family physician organizations like the Section of General and Family Practice of the OMA as well. So long as the government wants physician leaders, it appears they will have them.

The second essential component of a successful OHT is a robust health IT system that integrates seamlessly with the various organizations that support patients.

“In order to achieve benchmarks, ACOs rely on a strong population health technology infrastructure (and rely on EMRs to bridge this)” – Healthpayerintelligence.com

To put it charitably, Ontario’s current IT health infrastructure is a mess.  In the past 15 years, the government seemed to have absolutely no vision for an overarching health IT system that would put patients at the centre of the system.  We currently have three main hospital IT systems, about 7 physician-based EMRs (electronic medical records), multiple pharmacy systems, a home care system and a nursing home system, and none of them co-ordinate with each other.  Add in a multitude of radiology systems, and a separate system for all sorts of allied health care providers (Red Cross, St. Elizabeth, etc) and you essentially have a potpourri of systems, that unfortunately when put together emit an odour reminiscent of Pepe LePew.

Thankfully all is not lost.  The current government is taking a measured, thoughtful approach to the formation of the OHTs.  The first thing they are doing is introducing a Provincial standard for interoperability. Essentially this would be a secure format that allows, say, hospital IT systems to talk to Physicians EMRs and then to home care and nursing homes.  I suspect some legislation will be needed to force IT companies to adopt this standard, but it is long overdue and I’m glad the current government is finally implementing this.

The next step is where some challenges lie.  One of the goals of the current health care transformation is to allow patients to have more access to their records.  Several hospitals already allow this.  The issue is that different hospitals use different portals to allow access.  I’ve also seen some physician EMRs allow this, of course, all using their own portals. The last time I counted there were something like 70 Apps right now that purport to allow patients the ability to access their charts.  Clearly, there needs to be just on Province wide patient portal that allows patients to access their information.

To do this the government should simply partner with an organization that develops the patient portal.  Obviously, the organization could not be a for-profitentity (more to ensure privacy of data as opposed to any anti-capitalist sentiment on my part).  This would ensure that everyone in Ontario could use the same software to access all their records, and allow the seamless integration necessary for OHTs tosucceed.

There have been big changes in health care the past few months, with much more to come.  Thankfully the Premier’s Council on Ending Hallway Medicine is led by Dr. Reuben Devlin, who has a strong history of supporting IT to enable better health care.  Hopefully, the government will see the benefits of using a single Provincial Portal as a means of enabling the success of the OHTs. This would be a benefit for all Ontarians.