Category: Uncategorized

Re-Post: It’s Time To End The War On Drugs In Canada

NB: This blog originally appeared in Huffington Post Canada on Nov 3, 2015. With the demise of HuffPo it’s being reposted here for future reference.

As someone who had his formative years in the 1980s I can still vividly recall former First Lady Nancy Regan launching the ambitious “Just Say No” campaign. She championed this slogan as part of the “war on drugs.” This “war” was started by Richard Nixon in 1971. He declared that drug abuse was “public enemy number one” and that “the only way to fight this menace was on many fronts.” I can personally attest to having been a true believer in that policy myself, after having done some volunteer work in an emergency department as a teenager.

In recent years Canada of course, for the most part followed this policy. In our country, the main technique to fight this war appears to be conviction and incarceration of those caught with illicit drugs. For example, possession (not sale, but possession) is punishable by up to five years in prison. However, what’s clear is that this has failed to help the problem. Data from Statistics Canada (the most recent I could find) shows that while marijuana use in Canada has been relatively constant, the rate of cocaine and other drug use has gradually been increasing since 1977.

The drug trade itself has seemed to grow and is now considered to have a global value of over $300 billion (U.S.) per year. In Canada, as you can see below on this chart from Statistics Canada, drug offences continue to rise, while the total crime rate decreases. So certainly based on this data, it would be difficult to suggest that the “war” has been successful.

From an economic point of view, the costs of this war are even more staggering. It currently costs $117,000 a year to house a prisoner. Additionally, while the total overall rate of crime has decreased in the past twenty years, the incarceration rate is up, and 80 per cent of offenders have substance abuse problems. It’s clearly not hard to postulate that the main reason for the increased rate of incarceration is drug offences. 

As a family physician, I have seen first hand the effects of untreated drug addiction. Far beyond the relatively easy to measure economic numbers, lives have been ruined, families torn apart, some young women forced into the sex trade to pay for their habit and more, are all part and parcel of this terrible disease. Clearly, the goal of any national policy should be to take proven effective steps to reduce the rate of addiction.

The newly elected Liberal government of Justin Trudeau plans to legalize marijuana. To that end, my hope is that Canada can go one step further and focus on what works to reduce addiction rates. While it is clearly counter intuitive to suggest this, it turns out that the best way to do this, is to decriminalize the possession of small amounts of drugs.

While about 25 countries have decriminalized drugs, the best example of how this policy works is seen in Portugal. They decriminalized the possession (not sale, possession) of drugs for personal use in 2001. The offence was re-classified to an administrative offence as opposed to a criminal one, punishable at most by a fine. At the time, may people, myself included I might add, predicted that this would lead to an explosion of drug use, and that children would be targeted, and the nation would decay. As an aside, this rhetoric is similar to what Stephen Harper alleged would happen if we were to legalize marijuana in the last election. However, a review of the results 14 years later suggest that quite the opposite has happened.

Among other benefits, Portugal has seen a reduction in “past year” and “past month” drug use; a reduction in a dramatic decline in HIV and AIDS in drug users, a reduction in crime; a reduction in addicts in prison and a reduction in drug deaths. This has clearly been an extremely successful policy.

So what happens in Portugal when you are caught with 10 or less days supply of an illicit drug? Your case is referred from the Ministry of Justice to the Ministry of Health (a huge shift in and of itself) and you appear before a drug dissuasion committee. You may be fined, but more often are not and you are offered treatment for your addiction, part of which included social re-integration. Their rate of drug addiction has fallen in half since the implementation of the policy.

Ah, but these programs are expensive aren’t they? Surely it would cost a lot to provide this service for addicts. You mean more than the $117,000 a year we currently pay to incarcerate them? Which, as is proven, doesn’t work.

As mentioned, I was a true believer in the war on drugs, but at the end of the day, as a physician, I have believe in an evidenced-based approach. The evidence shows that incarceration doesn’t work, and decriminalization with offers of treatment do. It’s time to ignore dogma and act in the best interests of Canadians. It’s time to end this war.

Supporting Education the Key to Helping Developing Countries

I recently had the honour of being a guest speaker (along with the amazing Dr. Nadia Alam) at a fund raising dinner for Friends of Namal, an organization that provides university scholarships for students in Pakistan. The following is an abridged version of my speech.

I want to tell the story of a man who was born in Surat, in the State of Gujarat in India in 1933. He moved to Karachi in 1947 during the Partition, and as a teenager witnessed many of the horrors that occurred during that time. He was academically bright, but his family was poor and there was no way that he could afford a University education. However, in 1951 he became aware of a foreign students scholarship from McGill University, applied, and was successful. Four years later he became the first student in the history of McGill to complete his Chartered Accountant and Registered Industrial Accountant degrees simultaneously.

Mohamed Qasim Gandhi, who simultaneously completed the Chartered Accountant and Registered Industrial Accountant Degrees.

After that, he went back to Pakistan and worked for a number of years to support his extended family (his parents had died when he was young so he took care of his sisters who had raised him). In 1966, he and his young wife had a baby boy at the Holy Family Hospital in Karachi. Two years later, he went to Africa with his family as there was a better opportunity there. In 1972, when things got bad in Africa, he decided to move to Canada with his wife and son.

The rest of his family thought he was crazy. ”Where is this Canada place?” ”How far away is it anyway?” “Are there even any muslims there?”

And indeed, there was not much of a Muslim community in Toronto at the time. There was the Jami Mosque, one Halal meat shop on Gerrard street, and, well, that was about it. Not like today when, by the blessing of Allah there are mosques and halal restaurants seemingly every few blocks.

As you may have guessed by now, that man was my father. Because he brought me here at a young age, I didn’t really appreciate the significance of such a move. Truth be told, I really didn’t have great study habits. But one day, when I was visiting my Nana Abba (maternal grandfather), he recited a Hadith (a saying of the Prophet Muhammad, PBUH):

“The ink of the scholar is worth more than the blood of a martyr.”

I am aware that some scholars feel the Hadith is weak, but the sentiment is a good one and fits with Islamic principles. I took that message to heart, began studying harder, and was fortunate to have graduated from the University of Toronto Medical School in 1990. My Nana Abba came to my graduation ceremony. After that, he told me clearly that I was blessed to be an educated man, but now I had a responsibility to help others who wanted an education. I had to pay back my blessings by helping other people, no matter from what walk of life they came from.

So, after I finished my residency, I took over a family practice in a small town called Stayner……and my parents thought I was crazy. ”Where is this Stayner place?” “How far away is it anyway?” “Are there even any muslims there?” Funny how that works.

But I have now been there for 31 years, taught many medical students through the excellent Rural Ontario Medical Program, and seen the community grow significantly. Where once the muslim population of the area doubled just by me getting married, there are now 50 or 60 families, three halal restaurants and a Musallah (prayer site – not quite a mosque). 

Along the way, I managed to run into Dr. Nadia Alam through some medical politics. She convinced me that I should run for OMA Leadership (I still haven’t forgiven her for that by the way). Eventually this lead to me being the President of the Ontario Medical Association (I was the second Pakistani born president in its history, Dr. Alam was the first). This gave me the opportunity to meet many health care leaders, and politicians, and achieve things I never thought possible.

Dr. Nadia Alam, the first Pakistani born President of the Ontario Medical Association, as she gives a speech at the Friends of Namal Fundraising Dinner.

When I look back on this, I ask myself “How did this happen?” To my mind, there are two reasons. First and foremost it is because it is a blessing from Allah. Nothing happens without His will and whatever I have achieved is a result of His kindness.

The second reason of course, is because somebody gave a deserving young Pakistani student a scholarship in 1951, to let him get an education that he otherwise could not have afforded. This then, is the power of education and this then is why it is incumbent upon every muslim to get an education. Another Hadith:

“Seeking knowledge is an obligation upon every Muslim.” 

Note the wording. It’s not a request. It’s not a suggestion. It’s an obligation, a command if you will, that every Muslim MUST seek an education. Every Muslim. The Prophet PBUH did not believe there were “types of muslims” and did not distinguish between gender for eductation. Therefore, it’s also an obligation for those of us who can, to HELP other muslims get an education. 

We’ve seen what can happen when just one deserving student gets an education he could not otherwise have afforded. Imagine what can happen if five students do. Or ten. One hundred. More. Education is the key to making a better society and a better future for any country. I encourage those of you who are able to visit the Friends of Namal website, and contribute generously. 

Yours truly speaking at the Friends of Namal Fundraising Gala

Will the OMA Continue to Restrict Their Elections Process?

Ontario Medical Association (OMA) Election season is upon us again. The nomination period for people interested in running for leadership positions ended recently. This included a video promo in which a certain cantankerous old geezer contributed his two cents. But, will the OMA allow a proper elections process this time round, or will the OMA continue to impose stringent controls on the election process, thus ensuring banality, dullness, and an advantage for mediocre candidates (no really).

In the past, while campaigns for positions at the OMA have hardly been edge of the seat exciting (with many positions either acclaimed or unfilled), there at least was a spectre of campaigning that created some interest in the OMA and the elections process. However, that all started to change a few years ago, due to what I call the Nadia Alam rules. Unlike the real Nadia Alam, those rules desperately need to go the way of the Dodo bird.

Former OMA President Dr. Nadia Alam, the most widely beloved OMA leader in recent memory.

I actually remember when the controversy started. There was to be an election for President Elect. As part of that there was going to be a virtual Town Hall with the candidates. At the town hall, each candidate was asked some pre-selected questions. But then, some random questions were tossed in. And……the complaining began almost instantly after the fact.

“It wasn’t fair to toss random questions in.” “We weren’t prepared to be asked surprise questions” “It was designed to make us look bad.” Etc. The fact that answering unexpected questions might be a skill worth evaluating for a position that entailed a lot of media work, didn’t matter to the complainers. (I mean surely the media would never ever toss unexpected questions your way).

Immediately after my own induction as President, there was a minor controversy that popped up that I had to deal with, completely unprepared. Even the usually benign Medical Post tossed tough questions my way. This happens when you are the spokesperson for the profession (i.e. the actual job of President). Newsflash for those who complained – you didn’t look bad because the “process was unfair” – you looked bad because, well, you sucked at handling the unexpected.

But that wasn’t enough. The next rule that got put in place was to prevent former OMA Presidents from running for the Board, even if they have less than the six year maximum term limit. The reason was ostensibly that “we put our Presidents up on a pedestal and publicize them so much that they have so much name recognition”. Therefore it gives them an “unfair advantage” against others who would run.

To which I say, quoting former Toronto Mayor Mel Lastman – EL TORO POO POO!

There’s a whole bunch of ex-Presidents who, if they ran for something at the OMA, would get completely trounced because of their name recognition. This works both ways people. Do excellent people get positive name recognition? Of course they do. But it’s positive because they are excellent. They are exactly the type of people we need in leadership positions. The…..suboptimal people will get name recognition, just not the kind they want.

It gets worse. In recent years the Board election process has become so restrictive that candidates for Board are basically banned from campaigning. All they can do is have a statement and video message and, well, that’s about it. Heck they are all given a tool kit with “approved” messages to distribute on social media. Once again, this is to ensure “transparent, open and fair election” or some such thing.

Forgetting about the hackneyed nature of the “approved” messages, is it really to much to expect that people running for leadership might actually, you know, have the ability to communicate on their own? And would not the members be better able to judge candidates if they come up with their own messages, rather than some bland, inefficacious template from the OMA?

The problem with this of course is that the only candidates that benefit are the ones who haven’t, through their own hard work, built up their reputation amongst their peers or have the ability to effectively communicate with their colleagues. The mediocre candidates, who don’t have these skills are actually given a leg UP over better candidates because this process brings excellent people down to a mediocre level.

The result is an insomnia curing election process that resulted in barely 10 per cent of all members voting last year.

Why put all these rules in effect?. I’ll be blunt. In my opinion it’s because many OMA physician leaders (including Board Directors) were running scared of Nadia (in medical politics, she’s basically a one name rockstar like Beyonce ). They all knew that if she ran for anything, she would beat whoever she ran against. This is why I call these the Nadia Alam rules. They are designed to minimize the opportunity for someone who through perseverance and inherent excellence has become a great candidate. These rules were put in place to make it easier for the mediocre candidates (like themselves) to win.

I notice with interest that a few candidates for Board (whom I happen to think are excellent) have already announced on some well read physician social media pages that they are running for Board positions. I wonder if some of the usual complainers will be calling the OMA to say that this was “unfair”. This “gives them an unjust head start!”

Look, the reality is that life isn’t fair. Some people are better at being leaders than others. They should be allowed to promote their excellence as it is these excellent people that we need in leadership positions.

As for those candidates who seem to think they “deserve” to be put on an equal footing with those who are clearly better suited for leadership positions? I leave you with some thoughts from one of my favourite, satirists, George Carlin:

RePost: Inside Ontario’s Bloated Health Care Bureaucracy

NB: This is a copy of a column I originally wrote for Postmedia in October of 2015. It’s copied here so that I can access it easily in the future. And a sad reminder that as of 2023, things haven’t changed for the better. If anything, they are worse.

Ontario’s health-care bureaucracy has exploded over the past 12 years, mostly because the government has set up a series of arm’s-length agencies it can scapegoat.

I’ve experienced this bureaucratic mess first-hand.

From 2013 to early 2015, I was the lead physician for the South Georgian Bay Health Links. I took the position because I was told the goal was to co-ordinate care between various health-care agencies to better help patients with the most complex illnesses.

Then-health minister Deb Matthews said there were too many “silos” in the health-care system and anointed her then-associate deputy minister the “silo-buster.” The ADM told us to develop a local solution — because each area is different — and focus on our strengths to help these patients.

Our area is very fortunate to have an advanced IT infrastructure. Virtually all 60,000 residents have an electronic medical record (EMR) in a joint database. We are also one of only two regions in Ontario with electronic prescriptions. This process requires the pharmacy to have a portal that allows it to communicate securely, in real time, with the physician to discuss issues of clinical importance.

My patients have benefitted significantly from this technology, so our thought was to set it up with other allied health-care providers (home-care nurses, retirement and nursing homes, community support workers, etc).

The Ministry of Health funded Health Links through the Local Health Integration Network (LHIN). So we put a proposal together and took it to the LHIN. The LHIN’s IT department liked the idea, but wanted to get input from the ministry. The ministry liked the idea, but wanted us to get the input of eHealth Ontario, the independent agency trying to create electronic health records. eHealth told us to come to a “regional network meeting.”

At the meeting, they thought the idea was good, but asked for the ministry’s eHealth liaison to comment. The liaison referred it to the ministry’s IT group (yes, the ministry has both an eHealth liaison group and an IT group) who wanted to ensure compatibility with a “provincial solution” — even though we were told to develop a local one — and suggested we review with the LHIN IT department.

After a year of “circling back” (a phrase I learned from these guys that I came to detest) we finally gave up, funded the project ourselves for $70,000 — less than a salary on the province’s Sunshine List — and my complex patients are now starting to see the benefits.

As I have come to appreciate, the government set up these various arm’s-length agencies, such as the LHINs, eHealth, Health Quality Ontario, Community Care Access Centres and so on, rather than simply have the ministry accept responsibility for these tasks. From a politician’s point of view, this gives them the ability to deflect criticism by saying such and such agency is “independent.” For the most part, this has worked for the Liberals. They’ve won four elections in a row. But it certainly hasn’t helped the patients any.

My colleague, Dr. Shawn Whatley, posted a superb blog piece that looks at how many bureaucrats work in Canada’s health-care system. It shows Canada has three times as many bureaucrats as other countries with advanced universal-care systems. Even worse, Ontario has only 1.7 acute-care hospital beds per 1,000 people, which is about HALF the average for other OECD countries. Ontario got to this number by closing 17,000 acute-care beds — and laying off the nurses needed to staff them — between 1990 and 2013.

But at least the bureaucrats are producing meaningful reports and are happy to be helping with moving health system transformation forward, right? Not so, according to a recent survey of health leaders conducted by Quantum Transformation Technologies. Most respondents said they aren’t happy with Hoskins or the LHINs.

It’s dramatic just how badly health leaders feel the system is working. The comments at the bottom of the survey are equally telling. There are repeated calls to cut the number of LHINs and reduce the size of the bureaucracy.

So in summary, Ontario is burdened with a bloated, ineffective, and demoralized health-care bureaucracy.

Wynne and Hoskins’ solution to this? Lay off nurses and start a fight with doctors over their fees.

Franz Kafka couldn’t have come up with something this convoluted.

— Mohammad Gandhi, MD, CCFP, FCFP, is an assistant clinical professor at McMaster and Queens universities. 

* More than 1,000 doctors recently joined a Facebook group to complain about how the Ontario Medical Association, which represents them, isn’t sticking up for them in their fee fight with the province.

Earlier this month, the province cut funding for doctor services by $235 million, chopping doctor fees by 1.3%.

******************************

GROWING HEALTH-CARE BUREAUCRACY

* There are 0.9 health-care bureaucrats per 1,000 people in Canada, compared to 0.4 per 1,000 in Sweden; 0.255 in Australia and 0.23 in Japan. Germany has 0.06 bureaucrats per 1,000 people.

* Ontario has only 1.7 acute-care hospital beds per 1,000 people, which is about half the average for other OECD countries. 

*****************************

A recent Canadian Institute for Health Information (CIHI) report — the one Premier Kathleen Wynne and Health Minister Eric Hoskins say shows “Ontario has the best paid doctors in the country” — also says 12,000 Ontario nurses left the profession this past year.

* It also shows Ontario has only 176 physicians per 100,000 people (ranking 7th in Canada).

* Ontario has the fewest family doctors per 100,000 people out of all the provinces. Only 10% of family doctors in the province are accepting new patients.

* A recent Quantum Transformation Technologies survey of Ontario health leaders found 55% think Hoskins is doing a poor to fair job, 62% think the LHINs are doing a poor to fair job, and 50% feel the government has a poor track record of helping those with mental health issues.

Dear Premier Ford, You Know You’re a Conservative, Right?

Dear Premier Ford,

I’m not exactly your harshest critic. I actually support some (not all) of what what you’ve done in health care. Moving procedures from hospitals to outpatient clinics, building new hospitals, enhanced funding for paediatric mental health, are good steps. I hope there will be more commendable steps in the future.

Ontario Premier Doug Ford makes a health care spending announcement

However, I would be remiss if I didn’t point out that the health care system is going to be under a lot of fiscal pressure in the next couple of years. The remuneration that taxpayers pay for front line health care workers is about to increase drastically.

You will note, I hope, that I said “taxpayers” pay. I, like you in the past, try to avoid saying “government money”. The money to pay for health care and other services comes from the pockets of the little guy as a certain politician once put it. Calling it “government money” is just a way to deflect the public from the truth.

At any rate, you are no doubt aware that the nurses in Ontario got a well deserved 11 % arbitration award. You are probably aware that negotiations for a Physicians Services Agreement in Ontario are about to begin. Given that Manitoba just negotiated a record overall funding agreement with their doctors, and Nova Scotia doctors got a significant increase, you will not be able to hold the line against physicians getting an increase in Ontario.

Which of course means that many more health care workers will want an increase too. In short, there is going to be a lot of fiscal pressure on the taxpayer in the near future.

With that in mind, I will confess that my biggest disappointment in your management of health care is that I can’t honestly see that your government has reigned in the bureaucratic bloat that has so hampered the ability of front line physicians (and other health care workers) to look after patients properly.

Bureaucratic bloat is common in all government agencies. I greatly admire politicians who’ve made comments about needing to “end the gravy train” that provides jobs for bureaucrats and a myriad of consultants at the Provincial Government. Perhaps it’s because I live it daily, but no where does this gravy train seem to be so prevalent as health care.

Let’s look at digital health in Ontario for example. You have Ontario MD, which is an arms length agency that claims to be “the only truly provincial digital health network in Canada”, whatever that means. When I was on the OMA Board, OntarioMD was funded by taxpayers around $18 million a year.

But wait, you also have eHealth Ontario, that claims to be “creating a secure electronic health record information system so that all your medical information can be safely shared and accessed by your health care providers“. If I can decipher their audit statements correctly, they get a further $234 million dollars in revenue.

But that’s not all. The Ministry of Health has not one but TWO separate departments that appear to deal with health IT issues. Their organizational chart clearly shows a bureaucrat in charge of Health Services for an Information and IT cluster. She has her own team of well paid bureaucrats. Yet there is another bureaucrat in charge of Digital and Analytics strategy all with his own team of well paid bureaucrats. The Digital Health Branch of the Ministry of Health had a budget of almost $324 million in 2021/22.

And this is where the waste comes in. You have three agencies (one with two departments) to deal with one field, all reporting separately, none of whom necessarily agree with the other on what to do next. I saw this a lot at government when I was with the OMA. So progress was significantly impaired in digital health because not only was there not one vision amongst the agencies, but because every single issue went back and forth between the three agencies to try to get alignment (to cover the asses of the Sunshine List bureaucrats in case something went wrong). As a result, we are far behind every developed country (except the United States) when it comes to digital health.

I remember a politician who said:

“What drives me crazy is when you have a supervisor in government, and they report into 12 other supervisors. That’s unacceptable.“

That’s exactly what happens with the digital health care strategy in Ontario.

But moreover, the same thing happens in every single branch of the health care system. I mean seriously, if you already have a Clinical Care and Delivery Branch of the Ministry (see organizational chart) why do you need a separate arms length agency like Cancer Care Ontario? Or Ontario Drug Benefit? Or a myriad of others? They should be rolled up into the Ministry. There are many more examples but you get the point I hope.

If you were to simply stop funding OntarioMD (which in my opinion is no longer useful) and the scandal plagued, eHealth Ontario (which completely failed in its mission anyway), that would represent a savings of $250 million. At $100,000 each, that could pay for 2,500 front line nurses. Clearly nurses who provide front line care are more needed than bureaucrats who go around in circles.

The bureaucrats will no doubt fight you if you tried to do this. They will produce reams of power points and glossy manuals (all on the taxpayers dime of course) saying their work is important. But seriously, what would you expect from those who are accustomed to the gravy train?

Conservatives are supposed to be about reducing government waste, decreasing bureaucracy and efficient delivery of services. These are age old principles that, to be honest, I have yet to see from you as Premier.

If you don’t want to heed my advice, might I suggest that you instead take to heart the advice of the politician I mentioned above who wanted to end the gravy train and reduce the reporting to 12 other supervisors nonsense. That politician? A guy by the name of Doug Ford.

Respectfully submitted,

An Old Country Doctor.

RePost: 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.

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.

RePost: 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.

Purchase your membership