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.

iu-1

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.

iu-2

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.

Doctor’s Day Celebrated the Trust Patients Put in Us

“I love my Doctor and their team of colleagues. They are friendly and give me the best care I need. Thank you to Dr. Hameed and her team of Colleagues at St. Joeseph Family Medical in London Ontario.”
– Christine

“Dr. Gimbel is a super G.P. I have had issues from time to time, and Dr. Gimbel leaves no stone unturned until these issues are resolved. She has a good sense of humour, always listened to my issue and diagnoses them as speedily as possible. She is worthy of special mention on doctors day. “
– Roy

As President of the Ontario Medical Association, I am proud to lead an organization that represents so many remarkable people like Dr. Hameed and Gimbel. The public trusts us to protect their health and the health of their loved ones.

We repay that trust with a commitment to patients that often comes before everything else in our professional and personal lives. Ontario’s doctors keep the provinces 14 million people healthy, take care of them when they are sick and are vital members of our communities.

This commitment is the cornerstone of Ontario’s health care system.

For Doctors’ Day 2019, we asked Ontarians to share stories about their doctors and the difference they have made in their lives and communities.

Over the month of May, people across the province responded with moving personal stories like the two above.

Patients recounted how their doctor held their hand during their darkest hour, helping them to conquer illness or find the courage to keep fighting. They shared stories of doctors who went above and beyond and expressed admiration for the daily challenges that doctors overcome in the pursuit of excellent patient care.

This outpouring of support doesn’t surprise me. I know my colleagues well, and I’ve witnessed their daily dedication to their patients during my 27 years of rural medicine practice in Stayner.

I love practicing family medicine and value the trusting relationship between me and my patients. It is the same relationship Ontario’s 31,500 physicians have with more than 340,000 patients they see every day.

As president of the Ontario Medical Association, I will be writing a lot about issues that affect both the profession and patients in my term over the next year. I will post them on this blog, and on my twitter feed.

Ontario’s doctors are on the front line of the health care system. We see what is not working within the system and how it can be fixed. We understand that changes to the health care system must work for patients in real-life situations. As we work with government to fix our health care system, solve critical issues like hallway medicine and deliver high-quality care, the health and well being of our patients will always come first.

For more stories underscoring the strong and valued relationship we have with our patients, click here. I beam with pride in my colleagues when I read these, and I hope you do to.

Note:  The original version of this blog appeared on the OMA newsroom and the OMA facebook page.

Premier Ford Is Taking Promising Steps

Editorial Note:  This article was submitted for publication to the Huffington Post.  They published it yesterday (my thanks to the editorial team their for feeling it was worthy).  I’m republishing it here for those of you who don’t read Huff Po.

Ontario Premier Doug Ford sent a New Year’s letter to all members of the Ontario Public Service recently, announcing his three main priorities for the next year.  Happily, for those of us who provide front line health care, fixing Ontario’s troubled health care system continues to be one of those priorities.  Ford also specifically emphasized “embracing change and innovation, deploying technology more effectively, and committing to new models of collaboration and patient care.” But what exactly does that mean?

There’s been much written about the rather unique, even disruptive, style of the Ford government to date.  However, from a health care perspective, while Ford has moved quickly, he also, to date, seems to have moved pretty fairly – the hiccup around arbitration with the Ontario Medical Association aside.

First, he appointed Christine Elliottas Minister of Health (MOH). She’s clearly one of, if not the most experienced Minister in his cabinet.  Immediately after, deputy Health Minister Bob Bell retired, and was replaced by Helen Angus.  Helen Angus herself is a consummate professional and very highly regarded amongst the health care community.  There was clearly a feeling that steady hands were going to be on the tiller when these appointments were announced.

The first thing that Elliott and Angus did was streamline the MOH bureaucracy, reducing the number of Assistant Deputy Ministers from what looks like 21 to 11.  What’s that you say?  Didn’t former Liberal Health Minister Helena Jaczek state that that it was a myth that the MOH had a bloated bureaucracy?  Come to think of it, didn’t the former deputy Health Minister, the aforementioned Bob Bell, write that this was a myth too? Oops.

The next step was to hire Dr. Rueben Devlin to be the Chair of the Premier’s Council on Improving Health Care and Ending Hallway Medicine. I’ve had the opportunity to meet Dr. Devlin a couple of times. He’s smart, down to earth and has a strong background himself in providing front line patient care.  More importantly, he has a proven track record in embracing change, and deploying technology effectively.  He created the first fully digital hospital in the continent.  He showed me how some things work at his hospital, and I confess, I was drooling over how advanced they were.

It was just leaked to the media that the Government is looking at dissolving the dreadful Local Health Integration Networks (LHINs).  I’ve written about just incompetent LHINs were in 2016, so I personally am very glad to see them go.  The money saved from these wasteful behemoths of bureaucracy can be divested directly into front line care.

So, what’s next?  Having read through a bunch of information, I think we can expect the Premier’s Council to do the following:

  • Implement an IT plan of some sort, that has teeth to it. Ontario’s health care IT infrastructure was left in a complete mess by the previous Liberal government.  It is ridiculous that a patient in the Georgian Bay region has their health care team securely emailing each other about their case, but that nobody else in the Province can have this.  The fact that we still use fax machines (!) leaves us squarely in the dark ages.  The IT infrastructure already exists to modernize and streamline things.  We just need somebody in charge to say “make it so.”

 

 

  • Hopefully there will be an outreach to front line health care providers in their communities. Many of them know how the system is failing and have insight and ideas on how to fix things.  Giving them a true voice is important.

 

Premier Ford has a big challenge ahead of him with health care.  Our population is aging.  Health care technology is improving at a rapid pace.  Cost of care continues to rise.  But to these old eyes at least, it seems he has taken some reasonable first steps into getting a handle on the problem.  For the sake of all Ontarians, let’s hope he succeeds.

How Governments Try to Take Away Binding Arbitration

Binding arbitration. For Physicians across Canada it represents the only meaningful tool in a labor dispute with government. For moral and ethical reasons physicians are not willing to strike.  Physicians are an essential service for all Canadians. I believe the public recognizes and supports that.

Furthermore, not only does the Canada Health Act support binding arbitration for physicians, but so does a legal interpretation by Justice Emmet Hall, in his landmark review of medicare.  From Goldblatt Partners:

  • the Supreme Court of Canada has ruled that “binding arbitration must be made available to essential service providers, whenever society concludes that disputes over their compensation or working conditions should not be resolved by strikes”
  • Justice Hall rejected any notion that government could unilaterally reduce or determine payments to doctors, characterizing it as “wrongful conscription” of physician services. He concluded that, if legislation is to prohibit doctors from opting out of medicare (or extra-billing), it must also provide that “when negotiations fail and an impasse occurs, the issues in dispute must be sent to binding arbitration”.

Yet, Provincial Governments have been historically resistant to provide this tool for physicians. BC, Quebec and the Yukon still don’t have some form of arbitration for their physicians.  Nova Scotia tried to take it away from physicians in 2015, under the Public Sector Sustainability Act.  Of course, nothing unites doctors better than fighting a militant government (see Ontario under Kathleen Wynne!) and once the dust settled in Nova Scotia, there actually was negotiated agreement.  But the ensuing bad feelings seem to persist to this day as reports suggest there is still a “fractured relationship” in Nova Scotia, and needed health care reforms are being jeopardized as a result.

Why the resistance to arbitration?  Because some governments want to set a pay scale, rather than accept an arbitrator who will independently, and after thorough research, come up with a value of what a service is worth.

In Ontario, we are now seeing a few doctors taking steps that may well jeopardize the future of binding arbitration. As most physicians realize, a small group of specialists is attempting to break away from the Ontario Medical Association (OMA) and form their own bargaining group. Separating from the OMA would be a violation of the Representation Rights Agreement and of current legislation.

As I’ve mentioned previously, I really value my specialist colleagues. They’ve bailed me out on numerous occasions with sick, complicated patients. I couldn’t practice without their support.  But I think that in their anger over certain decisions made by OMA Council, they are not seeing the big picture here.

Any government is unlikely to have an interest in self-determination for specialists, or in picking sides. There’s no reason for any government to get involved in a “family squabble.”  All governments want a positive working relationship with doctors (on governments’ terms of course!).  To that end it makes no sense for a government to work with a small breakaway group, knowing it will upset the rest.  There’s no political gain there.

Ontario was the most recent province to get binding arbitration.  It took years of refusing to back down by physicians to get it. Even after then Premier Wynne offered it to physicians, it took months to negotiate the final binding arbitration framework (BAF).  The government wanted to include some unreasonable clauses in the BAF.

  1. They wanted to ensure there was a hard cap in the agreement (as opposed to letting the arbitrator decide if one was needed).
  2. They wanted the fiscal situation to be the main determinant of the award (not the actual value of the services provided).
  3. They wanted the award to be based on sustainability (the only way to sustain the system would be to cut physicians more).
  4. Most importantly, the government did NOT want CMPA rebates to be arbitrable (this would enable them to get rid of these in the future without negotiations).

It was only because the OMA Negotiations Team held fast to their principles that we got the fair BAF that we did.

So now, if some specialists try to separate, what then?  In an FAQ they distributed on Sunday, they have admitted the next step is to ask the government to repeal the Representation Rights Agreement (RRA) that the OMA has with the government.  And surprise surprise, guess what happens to be an appendix to the RRA, and would have to be deleted as well?  Why none other than the BAF (yes folks the BAF is part of the Rep Rights Agreement).  Essentially, if you repeal the RRA, you rip up the BAF for ALL physicians.

Frankly it seems unlikely to me that ANY government would  willingly offer a new BAF to any group of physicians.  Again, in their FAQ the small group only “believes the government shares the same view” on BAF as them, but they have offered no written proof.  To my mind, if any government does offer a new BAF to doctors, it seems likely that the ‘new’ BAF offer would have some or all of the limitations that the Liberals tried to force on us back in 2017.  (I would do the same if I was government.  That whole “all’s fair in love and war” thing).

I hope for the sake of my colleagues that physicians take a good long look before risking the unravelling of binding arbitration by supporting the break up of the OMA, and handing government the tools to undermine what we have achieved under our Representation Rights Agreement. We’ve been treated unfairly and fooled too often in the past.  Let’s not add to our woes by making it easier for any government to take advantage of us in the future.

Credit Where Credit Is Due

The College of Physicians and Surgeons of Ontario (CPSO)

As those of you who have read my blogs know, I have been quite critical of the CPSO. I respect the fact that their primary mandate it Is to protect the public.  However, in many cases I (and many other physicians) feel that they’ve going overboard in their investigations process.  Worse, I recently attended the Canadian Medical Associations National Health Policy Conference. I spoke my colleagues from across the country.  It became apparent that the relationship Ontario physicians have with their College is the worst in all of Canada.

Having said that, I confess to being pleasantly surprised at the recent introspective attitude of the CPSO. They presented on physician burnout at the International Conference on Physician Health. One of their own representatives, Dr. Peter Prendergast, noted the adverse effects on physicians of the protracted complaints process in Ontario. The additional burden they’re placing on physicians by not expeditiously dealing with frivolous cases, and how this contributes to the burnout crisis in medicine.  He acknowledged the need for changing a toxic system.

BurnoutToxic

This is the first time in my 26 years of practice that I can recall the CPSO making such a comment. I am grateful that they’re doing so. I suspect that this is because the CPSO has a new Registrar, Dr. Nancy Whitmore, who appears to be slowly changing (for the better) the way things are done there.  Many physicians will say there’s much more they can do, but I’m grateful for these first steps.

Canadian Medical Association (CMA)

Similarly, the CMA has been under a lot of fire from physicians recently. Tweets like this one, from former Ontario Medical Association president Dr. Scott Wooder, highlight the betrayal many physicians felt in this organization.

Wooder

Having said that I also need to acknowledge that the CMA has put a very strong emphasis recently on physician burnout. They were the sponsors of the International Conference on Physician Health.  CMA president Dr. Gigi Osler has been doing yeoman’s work to highlight this issue in the press.  At the National Health Policy forum that I attended, the CMA dedicate a lot of time on this issue, and is developing plans to tackle this growing crisis.

If the CMA continues to make dealing with physician burnout its main priority, it will do much to regain the trust that it is lost from its members. I sincerely hope that this will continue, and confess to being cautiously optimistic.

Ministry of Health (MOH) Reorganization

Last week, Global news obtained a copy of a letter from Deputy Health Minister Helen Angusindicating major restructuring at the MOH. The letter itself contained at the usual bureaucratic jargon, like this line:

“centralizing the responsibilities for LHIN managed health services under an associate aligned with key capacity, workforce and planning functions allowing for end-to-end management of health services for better outcomes and improved integration.”

The headache that I got from trying to figure out exactly what that sentence mean was not curable by a combination of 600 mg of ibuprofen and 650 mg of acetaminophen. However, a quick Google search shows that the object of the letter was to indicate a streamlining of bureaucracy.

Here’s an organizational chart of how the Ministry of health used to function:

Pre

Here’s an organizational chart how the Ministry of health will function now:

Post

Many people (myself included) will undoubtedly feel that this reduction in streamlining in bureaucracy does not go far enough. But it still represents the first reduction in bureaucracy at the MOH that I can remember in my 26 years of practicing medicine. It is a laudable first step.  MORE please!

One Last Thing:

As mentioned in the title to this blog, it’s important to give credit where credit is due.  The changes I listed above appear to all be steps in the right direction.  Perhaps I should allow myself a small amount of optimism for the future.

Or maybe….

Brown

 

Anger Leads To Bad Decisions

There were some interesting reactions to my last blog on the College of Physicians and Surgeons of Ontario (CPSO).  The most common (private) comment I got of course, was from colleagues saying they really liked it, but were too scared to share it in anyway on social media.  They didn’t want to be targeted by the CPSO.

The one comment that really stood out from me was by Dr. Darren Larsen, currently the Chief Medical Information Officer at Ontario MD.  Dr. Larsen wrote, “As professionals, why don’t we just treat each other with the same kindness and respect we would hope to be treated with by our peers and thereby stay completely off the CPSO radar screen?”  Dr. Larsen is right of course.  Having met him, I can also say that Dr. Larsen is genuinely one of the nicest people I know, and he absolutely always seems to live his life by the credo of being kind and respectful.  I’m happy for him that he’s able to do that.

Unfortunately, we are not all able to balance our lives like he has.

Currently physicians are overworked from trying to keep the health care system afloat.  When you crunch the numbers, Ontario has about 2.2 physicians for every 1,000 people.  In comparison, Germany has 3.8 physicians for every 1,000 people.  Heck even Bulgaria (!) has more physicians per capita than Ontario.  Coupled with an aging population and increasingly limited resources and bureaucratic inefficiencies, this leads to a significant increase in workload.  Physicians in Canada currently work over 50 hours a week plus call of between 20-25 hours a week.

The results of this crushing workload is entirely predictable.  The Medical Post recently did a survey on the best Province to practice medicine in.  My thanks to Dr. Dennis Kendel for tweeting out the chart below:

Work:Life

The most telling line is the one on work life balance.  Not a single province scored higher than “C” on this one.  Four provinces (including Ontario) got “F”.  A most telling table that gets to the heart of the issue of physician burnout.

Being human, physicians of course are subject to the same flaws as everyone else.  They don’t like to admit it mind you, but when the work/life balance gets skewed, physicians get irritable, depressed, make mistakes, and yes, say dumb things on social media that they wouldn’t otherwise.

More recently, I have noticed this irritability turn into anger amongst physicians.  In Ontario, physicians are going on over five years without a contract.  While we are still getting paid, the uncertainty of the situation is weighing on us.  Middle aged to older physicians are feeling the effects of years of mistreatment by the previous government and getting increasingly bitter with each passing day.

Even younger physicians have been affected.  Many trainees that I’ve spoken to (I’m a preceptor with the Rural Ontario Medical Program) are uncertain if they’ll be able to practice.  Turns out that despite an aging population, Ontario has unemployed physicians.  The situation is particularly acute in family medicine, where the government unilaterally slashed the number of Family Health Organization spots in half, leading to a new crisis in Family Medicine.  So even newer docs are feeling bitter.

I worry a lot about my colleagues.  We all know that making decisions out of anger and bitterness will generally lead to bad outcomes.  This applies equally to whether we are making decisions on patient care, or on issues like contracts, negotiations and especially medical politics.  We must base our decisions and actions on facts, and not frustration, no matter how justified that frustration may be.

Dr. Larsen also wrote: “….it is a privilege to be part of a self regulated profession. With that privilege comes responsibility.”  Again, absolutely a true statement and one that is hard to argue with.  But I happen to feel that the responsibility should apply not only to ourselves as individuals, but to regulatory bodies like the CPSO and also to member organizations like the OMA.  The OMA is planning a Task Force on the burnout issue, and will hopefully make some meaningful recommendations that can help with this issue.

To my colleagues, I once again ask that you do your best to look after yourselves.  Eat right.  Exercise regularly.  Take regular breaks from work.  Don’t feel guilty for taking a day off now and then.  Ask yourself if the decisions you are making are from anger, or based on facts.  Above all, try to be kind to your fellow colleagues.  They are probably feeling just as frustrated as you are.