justanoldcountrydoctor

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.

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.

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:

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

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….

 

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:

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.

Disclaimer:  As always, the views below are mine, and do not represent those of the OMA, even though I happen to be the President- Elect.

The College of Physicians and Surgeons of Ontario (CPSO) governs, licenses and oversees the conduct of Ontario’s physicians.  Through a combination of a tone deaf, paternalistic attitude, and fear that “bad press” will lead to a loss of something called self-regulation, the CPSO has sadly lost the respect of physicians across Ontario.

Instances of poor physician behaviour continue to be (thankfully) very rare.  Despite this, it is safe to say that the CPSO has been under siege in the media.  Some of it is their own doing.  The CPSO actually once went to court to try to get a decision that their own Discipline Committee made enhanced – in effect they sued themselves.  Some of the media siege is due to zealous reporting (stories of “rich” doctors doing bad things sell newspapers).  Regardless, the media has clearly not been kind to them.

The CPSO response to the media was shockingly defensive.  Rather than trying to ensure a fair complaints process,  they decided to double down and severely prosecute physicians for truly ridiculous reasons.  The perception amongst front line physicians is that the CPSO is trying to “look tough” to get the press off their backs.

The most egregious example of this by the CPSO occurred during the debacle that surrounded the failed tentative Physician’s Service Agreement (tPSA) of 2016.  Emotions ran high in the profession  and physicians, being human, said things that they would not normally say.

Some of these things were clearly inexcusable no matter what the situation.  The CPSO was right to discipline physicians who repeatedly sent abusive emails to former Ontario Medical Association (OMA) President Dr. Virginia Walley.  But they went overboard in many cases.

When someone comes to my office who is angry, and using foul language, the CPSO expects me to show some compassion, try to find out why they are feeling the way they are, and work with them to reform them.  Yet the CPSO refused to extend that humanity to physicians who committed minor infractions.  Would it really have hurt the CPSO to ask these physicians if they were feeling burnt out, considering the magnitude of the physician burn out crisis?

I will not embarrass these physicians more by linking to media reports, but I will state for that record that the following physicians were disciplined, paid at least $10,000 each to the CPSO, and publicly shamed:

• one physician, who replied to an anonymous email address with “stop sending me these f$%@#$ emails”
• A physician who called Health Minster Eric Hoskins a “reichmaster” on facebook
• Another physician who called Hoskins a “F@$% P#$&*” on facebook
• A physician, who told a clearly inappropriate joke on a private electronic forum

NO patients were harmed.  NO medical incompetence was exhibited.  NO threat to the public.  And NO humanity exhibited by the CPSO to see if these physician were feeling all right.  If using the “f” word is cause for discipline, then judging by her Twitter feed, Dr. Jennifer Gunter, a leading expert in the fight against pseudoscience, had best not re-apply to practice in Ontario.

Worse, the CPSO exhibited a clearly one sided approach to how they meted out discipline.  In the aftermath of the tPSA, the OMA Executive faced a non-confidence vote.  Dr. Philip Berger, who has a well deserved reputation for social activism, decried the leaders of the non-confidence motion as “right wing coup plotters”, “dictators”, “fanatics” and so on.  Full disclosure, he is referring to me, current OMA president Nadia Alam and others.

In response, one physician on a facebook forum suggested Berger should take Ativan (a mild tranquilizer) and another suggested a stronger tranquilizer.  Guess who the CPSO decided to investigate, even though a formal complaint was NOT laid? (The CPSO can investigate at the discretion of their Registrar).  Guess who DIDN’T get investigated for making unprofessional comments about another colleague at the discretion of the Registrar?  The message from the CPSO was clear.  You can disparage another physician only if you have the right political view point.

For the record I will not lodge a complaint against Dr. Berger for disparaging me.  It would be a stupid, idiotic waste of the College’s time, and it was pathetic for the CPSO to wade into this in the first place.

More recently, workers striking at a family practice clinic wrote an open letter to the CPSO complaining about physician behaviour in a clear negotiations tactic.  Instead of realizing it for what it was, the CPSO instead sent their communications director to follow up and “offer support in filing a formal complaint.”  The fact that they were completely blind to this being simply a negotiation tactic is befuddling.  This was proved when the doctors in Owen Sound stated that the union withdrew the complaints as part of the negotiated settlement.

In fairness, new CPSO Registrar/CEO Nancy Whitmore appears to be trying to change all that.  She has promised efficiencies in the painfully long complaints process.  This would allow her staff more time to deal with serious complaints about physicians’ competency and misconduct, while quickly dismissing frivolous ones.

Additionally, I confess that I’ve been pleasantly surprised at how co-operative the staff at the CPSO have been with the OMA to modify the Continuity of Care Policy.  The original policy would have placed unreasonable bureaucratic burdens on physicians, and might have killed off family medicine and walk in clinics.

These are welcome changes in approach and should be lauded by every one.

I do feel Dr. Whitmore genuinely cares for physicians, and wants a fair process to help them and protect patients.  However, this might be seen as too little too late by many members.  The CPSO has governed the profession by fear (instead of respect) for so long that physicians are extremely jaded about the organization.  Public dissatisfaction with the CPSO doesn’t help either.  Here’s hoping that Dr. Whitmore can maintain the reform minded approach she has initiated.  It will be best for patients, physicians, and the CPSO.

“That’s the thing about trust. It’s like broken glass. You can put it back together, but the cracks are always visible–like scars that never fully heal.” 
― Hope Collier

A fifteen year old comes to my office.  She’s pregnant.  She’s petrified because her mom and one of my staff are good friends, and her mother doesn’t know.

A thirty year old man, with a long history of mental illness finally admits he was sexually assaulted as a child.  He didn’t tell me sooner as the abuser worked with the husband of one of my employees.

A couple is having marital problems.  There are affairs and now sexually transmitted diseases involved.  They’re trying to work it out, but were scared to seek help as one of my staff goes to the same Church.

I’ve seen all of this, and much more, practicing medicine in a smaller centre.  I would not have been able to manage these tricky situations if it had not been for the trust that I have in my staff.  Like all family physician’s staff, mine have access to a great deal of personal information.  I cannot effectively do my job without implicitly trusting them to ensure that confidential information stays confidential.  I rely on them to skillfully do tasks I assign them for patient care.  But I also trust the judgement that they have about certain situations and certain patients (they have a wealth of social knowledge that is invaluable to me).

This implicit trust is the hallmark of a high functioning health care team.  Each member of the team is valuable, and each carries out their duties, knowing the other member will carry out theirs.  This does not mean that we always agree on everything.  Healthy discourse is important.  But it means that at the end of the day, we know we will act in a patient’s best interests.

Which brings me back to the miserable situations in Owen Sound and Thunder Bay.  In Owen Sound, to try to make up for his failure as a leader, OPSEU President Warren “Smokey” Thomas wrote to the College of Physicians and Surgeons (CPSO) to complain about the alleged tactics used by the physicians in the dispute.  Let’s be clear, when you complain to the CPSO, you are threatening a physician’s career.  A complaint should only be made in an egregious situation (for example sexual assault) and not over a pay dispute.  Smokey himself is a nurse.  He should have known this.

The situation in Thunder Bay is worse.  Last week, under the leadership of Unifor President Jerry Dias:

• One of the strikers allegedly assaulted a patient
• The Union erected a metal fence overnight around the clinic and blocked access to patients attending appointments to see the physicians
• Despite a court injunction, the Union left the metal fence up and prevented patients from being seen for a second day
• Somebody glued the door to the clinic shut over night, and cut power to the building in what can only be called a criminal activity

Ontario Medical Association President Dr. Nadia Alam, stated that over 1,000 appointments were cancelled.  Many had travelled 100s of kilometres.  Many had been waiting for months for their appointments due to the severe lack of specialists in the North.  Cutting the power caused loss of vaccines and, as the only fertility clinic from Sudbury to Winnipeg, also a loss of sperm and egg samples.

Eventually, these disputes will end one way or another.  But what will never, ever be the same, is the trust between physicians in these clinics and the staff.  How are the doctors in Owen Sound going to trust employees who threatened to end their careers?  We are not talking about large corporations that make widgets where workers on the line never meet their boss.  We are talking about smaller, intimate offices where everybody knows everybody.

In Thunder Bay how exactly are the doctors there supposed to trust employees whose actions, however indirectly, led to alleged assaults, physical threats and intimidation and vandalism?  Unifor is denying responsibility for the vandalism, and no doubt will disavow assault/harassment as a tactic, but the blunt reality is that without the fence, none of the other stuff would have happened.  No wonder a number of physicians are considering leaving Thunder Bay.

Worse, what does this mean for the type of health care that is going to be provided in these areas?  The patients of Ontario have a right to high quality health care.  As mentioned, when there is no trust within a team, health care will suffer.

The stories of Owen Sound and Thunder Bay have gone viral in the medical community.  Both areas are short of doctors.  How they will now recruit new physicians in the current environment is beyond me.  The reality is that physicians are fortunate to have multiple options when they choose an area to practice.  Why would any sane person go to these toxic environments?  How will Thunder Bay replace physicians who leave?  The stench from these messes will take years to fix.

The biggest losers are the employees of these clinics.  They made a legitimate request for raises and improved working conditions.  Unfortunately, they put their faith in two Union men, who clearly didn’t have a clue about how health care offices work.  They used tactics more suited for factories, not physicians offices.  The tactics have failed miserably (four months and no contract yet).  In Owen Sound, 40% of the employees have quit, recognizing Thomas’ inability to get the job done.  In Thunder Bay, if physicians leave, there will be job losses amongst employees there as well.  Worse, the employees will be blamed for worsening access to health care, if doctors do leave.

The employees of these clinics deserve strong, effective and appropriate representation.  Sadly for them, they are not getting it from OPSEU and Unifor.

Not a full blog this time.  But for those of you who don’t follow me on twitter (@drmsgandhi), I just wanted to bring your attention to two blogs.  Both deal with the deteriorating situation in Thunder Bay where a union (in this case Unifor) has, as a result of their actions, denied health care to over a 1000 patients.  Many of these patients were elderly, and many had waited months for a specialist appointment.

The first blog is by the President of the Ontario Medical Association, Dr. Nadia Alam, and can be read here.

The second is by the Past President of the Ontario Medical Association, Dr. Shawn Whatley, and it can be found here.

I encourage you to read both of them.

View at Medium.com

I’ve had the pleasure of being a doctor for 28 years now.  I’ve long since appreciated that in order to provide the best care to patients, members of a health care team (doctors, nurses, pharmacists, allied health care providers and yes, even clerical support staff) must trust each other, and must work collegially and co-operatively.  Without that collegiality, the team fractures and the patients suffer.

This is why many physician leaders over the past few years have  advocated for more funding for Nurses, PSWs and other front line health care workers.  I’ve seen first hand how nurses and PSWs go above and beyond for patients.  My patients need positive, happy, engaged allied health care providers to serve their needs.

Unfortunately the recent actions of OPSEU president Warren “Smokey” Thomas and Unifor President Jerry Dias (both old school union types) show a total disregard for health care teams and patients.  They have reacted to some sort of labour dispute amongst the staff of the Owen Sound Family Health Organization (or FHO) and the owners  (essentially about twenty family doctors), by using old school divisive union tactics that may have a place in private business – but will hurt the patients of Ontario.

First, a full disclosure.  While I happen to be President Elect of the Ontario Medical Association (OMA), I actually don’t know any of the doctors in the FHO in Owen Sound.  I’m also not familiar with the situation there, other than what I read in the media and press releases.

But I do know that doctors have been warning that cutting patient services, like the Liberal Government did unilaterally, would cut staff and even close clinics.  Cutting physician funding is a cut to physician clinics, patients services and the staff who work there.

This is why it is so irresponsible Smokey and Dias to publicly shame physicians who own the clinics on social media.  I will not include a copy of OPSEU’s Facebook ad, but it basically implores people to “Tell the doctors….to get back to the table with a decent offer.  They can afford it.”  Then a list of all the doctors in the FHO is provided.  Smokey and Dias are now calling on patients to make an appointment with their doctors, to advance a political agenda.  At a time of wait lists and family doctor shortages, that is an appointment that could have, and should have, gone to a sick patient

Targeting employers is an old union tactic.  There are always ads from Unions advocating for membership on radio, TV and the internet.  But doctors are not big for-profit business. They’re not big box stores. They’re not giant corporations. They do this work because medicine is a calling. That’s why so many are offended by these ads.

Smokey and Dias also think suggesting doctors don’t know what they’re doing is a good idea.  They’ve spearheaded the “Without us, your doctor is just guessing” campaign which suggests that physicians can’t diagnose a disease based on, you know, talking to and examining a patient.  Can you just imagine what would happen if the Ontario Medical Association were to launch a campaign that said “Without Doctor’s Orders, Nurses Would Have No Direction?”.  (NB – The OMA won’t do that, we have too much respect for the nurses).

Suggesting that physicians work in “for profit clinics” that are analogous to private care (when everything is publicly funded) is another ridiculous statement.  Again, this is basically an old union tactic.  Go after “the rich” and “greedy capitalists.”  Use the politics of division to frame your members as the “have-nots”, the “poor” and the “oppressed” to garner public sympathy.  Embarrass the corporations into giving you what you want.  It may work in the real private sector, but these kinds of derogatory comments are only going to harm health care, and their own members.

Firstly, all health care workers, including physicians, are paid by the government of Ontario via your tax dollars. Obviously some workers (even some physicians) are salaried, some get a portion of physicians billings and some are on a bit of a hybrid model, but the money all comes from the same spot.

Secondly, Not sure how what Smokey’s long term strategy is, but is seems to me that attacking allies that have advocated for more funding for front line health care workers (OPSEU MEMBERS!) isn’t a great idea. Maybe Smokey is taking a page out of the Donald Trump school of leadership.

Thirdly, I don’t think Smokey and Dias have considered the damage that will be done to patient care.  Care teams for patients (particularly in family physicians offices) are smaller, more intimate and absolutely must work well together for patients to receive optimum care.  By using such divisive tactics in a small office they are sowing dissent and mistrust.  It’s really hard to see how trust will be rebuilt in the future.

Health care in Ontario has been in a crisis for many years know.  For the sake of the patients, physicians and allied health care workers need to work cordially and co-operatively to promote optimum health care planning for Ontario.  Smokey and Dias have started a bit of dumpster fire with their actions.  It’s a pity they don’t realize that.