OMA Fails Family Practice with Virtual Care Agreement

Recently, the Ontario Medical Association (OMA) approved an agreement to extend virtual fee codes for an additional year. There is much to like about the extending fee codes for virtual care. As the pandemic has taught us, there is a role for appropriately provided virtual care. I have used virtual care with my patients for over three years now, and have found it a useful adjunct to in person visits.

In the current environment however, the extension agreement fails family practice. Since family practice is the bedrock of any high functioning health care system, damaging it will have unforeseen negative consequences.

How will this agreement harm family practice? By allowing negation to occur for care that is provided virtually, without implementing some guidelines on the appropriate provision of virtual care.

About 6,000 of Ontario’s family physicians are on a capitation model (basically a salary plus performance bonuses). One of those performance bonuses is for accessibility. The bonus applies if your practice is available to look after your patients. If, for example, a patient can’t see you, and then goes to see a walk in clinic that you don’t work it, the family physician in question will be deducted the value of the visit to the walk in clinic.

The concept of the access bonus is a good one that I support. We’ve got ample evidence that the absolute best health care outcomes occur when patients see their own family doctor as opposed to seeking out itinerant care from physicians who with whom they don’t have an ongoing relationship.

So what’s the problem then? Why should negation of the access bonus apply only to in person visits, and not to virtual care as well? Because the current landscape for virtual care is so open ended, and so rife with potential for overuse/misuse, that it makes it impossible for family doctors to compete on the availability and ease of access front.

There are lots of private, for profit companies that provide a level of virtual care, but for simplicities sake, let’s look at dot health. A glance at its website reveals that, for the low low price of $69.98 per request, you can get your health care information (including labs/diagnostic tests/clinical notes apparently) from providers, and store it securely on the web where you and only you can access it. The website doesn’t go into the two tier nature of the system – those who can afford to pay for multiple requests can then present their data to a new health care provider they meet and presumably get more appropriate care.

More troubling to me personally is the “free” service offered by some guy (I’m assuming he’s a he based on the icon) named “Dr. M” offering to help you “understand” what your records mean to you.


Patients should be able to understand their own private health information/records. But surely it makes much more sense to ask the doctor that you already have a pre-existing relationship with what the records mean. You know, the one who’s followed you all along, and you’ve seen regularly. Asking essentially a stranger on the internet (no matter how well qualified) seems problematic at best.

I have no idea if “Dr. M” bills OHIP for the phone calls he would provide to patients who request this service. I would simply point out that under the existing virtual care codes, if a patient requests this service, it would be legal for him to bill. This would result in the family doctor for the patient being negated.

Also problematic in my opinion, is there seems to be a consolidation of sorts in private for profit virtual care companies. dot health’s website offers seamless integration with Maple.

Another screen shot from dot health’s website, where they offer connectivity to Maple

Maple is a private, for profit virtual health care provider that allows you, for a fee of course, to chat with a doctor/nurse/nurse practitioner and get care through their patented app. Maple was recently bought by Loblaws/Shoppers Drug Mart for $75 million (!).

And no surprise, their focus appears to be on “convenience”. Here’s the example they use from their own website:

Seriously, diagnosing strep throat, without a throat swab (which can only be done in person)?? And then prescribing antibiotics (I wonder which pharmacy gets the prescription). Have these guys never heard of the issue around over-prescribing of antibiotics and the ramifications? Or the fact that the vast majority of sore throats are viral?

The astute amongst you will also recognize that dot health was founded by Ms. Huda Idris. Who also happens to be a Board Director for Ontario MD, the OMA subsidiary that is supposed to be the “Trusted Advisor for EMRs and Provincial Digital Health Tools” for physicians.

To be clear, I have a great deal of respect for Ms. Idrees as a person. Being from the south Asian community and a Muslim myself, I think it’s incredible that we have role models like her out there given some of the patriarchal attitudes that persist in that community. I congratulate her on her success and wish her more of it.

However none of that changes the fact that having the owner of a virtual care company, that has links to another, while OMD is supposed to be taking an impartial look at virtual care solutions going forward creates the impression of a conflict of interest. She likely would recuse herself from discussions around this (she has a reputation for impeccable conduct) but in politics, the reality is that a perception of a conflict of interest, might as well BE a conflict of interest

NB – I should point out that OntarioMD likely had nothing to do with the virtual care extension agreement – that was approved by the OMA Board.

Back to accessibility, I pride myself on being reasonably available to my patients. As with all things, there are some ups and downs, but I have consistently had positive access bonuses for the past 17 years. I have no problem with other clinics trying to set up shop near me (some have tried over the years) because my patients generally know that for the most part either via phone, email, or in person, they can usually get a hold of me in a timely manner.

However it’s not possible for me, or any other family physician, to compete with $75 million operations like Maple or companies like dot health who advertise on Twitter and Facebook, and allow people to simply click on the ads to connect to a physician.

Moreover, this kind of thing is bad for the patients. The example of prescribing antibiotics without a throat swab is just one of many that I could present about inappropriate tests and or prescriptions being given by physicians who may mean well, but don’t know have the insight an ongoing relationship with patients can provide.

This deal will also potentially negatively affect specialists as well. Say you are the best cardiovascular surgeon I know. At some point these private companies will also have other cardiovascular surgeons on staff. Maybe if a patient has a question about their surgery, they will contact, for convenience sake the private company, instead of asking you. Do you think that’s not going to affect consistency and quality of care?

Virtual care is here to stay and I support virtual care. However, when funding virtual care it’s important to ensure that it’s only funded in an appropriate manner. As Drs. Agarwal and Martin wrote in their piece on the virtual care revolution:

“Virtual care should be leveraged to as a tool to interact with your provider – someone who knows you and can see you in person when that’s best.”

Currently, there appear to be no qualifiers on virtual care payments. Maybe there was a sense that the only way to get qualifiers was to approve this first. Maybe the concern was that time was running out on the initial agreement and something had to be done now. I don’t know (I’m not on the OMA Board anymore).

But I do know this, sometimes, you need to walk away from flawed agreements for the sake of the greater good. And this, was a flawed agreement that should not have been approved.

Vaccine Certificates/Mandatory Immunizations are a Bad Idea

First things first, if you’ve read the title of this blog, and are hoping to find ammunition to promote a vaccine hesitant agenda, you won’t find it here. Go watch Fox News or Newsmax or any other QAnon affiliated vaccine disinformation service.

The COVID vaccines are safe and they are incredibly effective. Something like 99.5% of all patients in hospital ICUs with COVID are people who have not been fully immunized. Many of them beg to get immunized after getting sick, but by then it’s too late.

Frankly, I think an argument could be made that the mRNA COVID vaccines are the most effective vaccines science has ever developed. If you remember nothing else from this blog – remember this – I encourage you to all voluntarily get vaccinated for COVID, especially now that we seem to have adequate supplies.

Making vaccines mandatory/vaccine certificates however, introduce a whole new set of concerns that I don’t think have been well thought out.

The rationale for introducing Vaccine Passports/Certificates appears to be to protect society. By requiring documentation that you have been vaccinated prior to allowing you to go to a restaurant/travel in Canada/attend sporting events etc, the thinking is that you will prevent the spread of COVID.

The argument for making COVID vaccinations mandatory for health care workers is that patients should feel safe when accessing health care, and be assured they won’t get COVID19 from someone who is treating them. The point has also been made that health care workers are often required to show proof of immunity to things like Hepatitis B and Tuberculosis. So why not add COVID to the list? (Interestingly, those who espouse this view conveniently forget that health care workers are not required to immunize yearly for the flu, and the flu kills far more people every year than either TB or Hep B).

But.

One thing this pandemic has taught us, is that there is a small group of people out there who are extremely mistrustful of authority. They won’t trust doctors/public health officials/nurses etc. They prefer to do their own “research”. Their “research” is frankly guided by confirmation bias (looking only at information that supports your agenda, as opposed to looking at all the facts, whether supportive or not). These people then (sadly very successfully) use social media to spread their half truths (and in the case of noted health experts Donald Trump and Tucker Carlson – outright lies).

The damage caused by these people is in calculable. COVID appears to be resurgent in the United States and is being (rightfully) called a pandemic of the unvaccinated. Third world countries are struggling with another wave, and are desperately trying to keep their health systems afloat, while they get the needed vaccines. International travel remains in limbo, and the economic damage caused worsens by the day.

So why then are vaccine certificates or mandatory vaccinations for health care workers a bad idea?

Because no matter what I or other health officials think of the idea, the simple reality is that the vaccine hesitant crowd will spin this as co-ercion.

Celebrated Infectious Disease Specialist Marjorie Taylor Greene discusses the pros of Covid Vaccination (sarcasm fully intended by writer)

And that, in a nutshell, is why I oppose the idea of vaccine certificates, and mandatory vaccinations. We have the weight of evidence on our side that vaccines work. We have been able to debunk many of the stories about the COVID vaccines (remember when the Pfizer vaccine was going to cause an outbreak of Bell’s Palsy and we were all going to walk around with half droopy faces?). With each passing day seeing only unvaccinated people being admitted to hospital with severe COVID we keep building our case. We should be pro-actively promoting all of this in order to let the vaccine hesitant know that their concerns are unfounded.

One thing that has been badly done during this pandemic is the dissemination of information. In any crisis, the first thing to do, should be to have clear, consistent, factually accurate communication. This has been sorely lacking in the past 16 months with health authorities disagreeing with each other.

Yet now, we are again running the risk of doing the same thing. On the one hand, we’ve got experts (quite correctly) proclaiming the vaccines are the best way to prevent COVID.

And now health authorities are turning around and essentially saying ” yah, but we’re going to make you have a special passport to go anywhere so you are protected.”

What exactly do you think those that are already suspicious of authority are going to think? They are simply going to double down on their belief that we have to be “forced” into getting a vaccine, because it’s really not as good as we say it is. We’re going to lose any chance of trying to build bridges with the vaccine hesitant crowd, and win them over with the force of reason and facts (which is overwhelmingly on the side of those who believe in vaccinations).

The whole point of taking the incredibly effective COVID vaccines, is so you can go places and NOT WORRY if the other person is unvaccinated. Even if you are exposed to COVID, it will be the unfortunate misguided unvaccinated individual who will get sick, not you.

Building trust with the vaccine hesitant crowd is hard. It takes time, effort, repetition of facts and a calm approach. But if we go down the road of creating the impression of co-ercion, we’re going to embolden hesitancy and create more fear and mistrust. Vaccine hesitancy will only rise as a result and mistrust of health authorities will increase. Who knows what the long term implications of that are? I worry those implications will last beyond the pandemic, and will cause ongoing problems for health care in the future.

We have facts/reason/data to support the COVID vaccines. Let’s keep promoting that, and not give those who mistrust health authorities, more ammunition.

The Promise That is Canada

A few years ago, a (now deceased) patient of mine was in the office. He had just come out of hospital and he thanked me for looking after him. He then told me I was the best doctor he ever had. It was a touching moment which I’ve always cherished, and was planning on keeping private. But it’s what he said afterwards that I will be reflecting on this Canada Day.

He went on to tell me a little bit more about his life history. I knew that he had immigrated to Canada from Germany, but really not much else about his youth (he was a very private person). He opened up and told me that when he was sixteen, he was a member of the Hitler Youth of the Nazi Party. He fought in World War 2 for the Nazis, where he was eventually shot and captured by Allied forces.

But he also admitted what must have been some very uncomfortable truths for him to retell. He told me when he was a teenager he believed the propaganda about the Germans being the “master race”. He bought into the anti-semitism at the time. He used to look scornfully at people who weren’t white when he was a teenager as he firmly believed what he had been taught – that people of colour were inferior.

After the war, he had a number of odd jobs and eventually immigrated to Canada. In Canada he saw people of all races and ethnicities living and working, mostly respectfully and peacefully together. He worked with, and for, people of many religions and came to realize the errors of his youth. He realized just how wrong the Nazis were in their beliefs. Eventually, he wound up in my practice and I viewed it as an honour and privilege to care for him in the last stages of his life.

I mention this because this Canada Day is going to be one of the most sober ones I can recall. Many are actually tweeting out that we should #cancelcanadaday in light of the many horrific things we have discovered about ourselves and Canada these last few months.

Hundreds of confirmed unmarked graves of Indigenous children, with likely many thousands more yet to be found. Buried in mass graves without anyone to remember them, or their families to carry out traditional ceremonies to honour their children and share their grief.

An Islamaphobic act of domestic terror against an innocent, hard working family in London, Ontario, robbing Canada of four remarkable people who were contributing to making Canada a better place and a better country. Despite the horror and revulsion we feel at this act, there continue to be ongoing Islamaphobic acts such as a man having his beard forcibly cut off, women targeted for wearing a hijab, and attacks on politicians for just saying we must fight Islamophobia.

Anti-Semetic attacks in Canada continue to increase, such as painting swastikas on synagogues and various forms of harassment and violence. A disturbing rise in anti-Asian hate crime and violence, likely incited by people who initially blamed China for the Covid-19 virus. While it’s true that the Wuhan Lab-Leak theory for Covid19 has gone from the realm of tinfoil conspiracy theorist nonsense, to possible, it is egregiously wrong to blame the Asian-Canadian community that has contributed so much to our culture .

And of course, ongoing racism and marginalization of our Black community, even in medicine continues.

I’m sure I’ve missed many groups, but you get the point. This Canada Day, we are coming to grips with the fact that Canada has many flaws and much room to improve. This is particularly true for immigrants like myself who (still) truly believe that Canada is the best country in the world. To see so many failings exposed in a country you love is heartbreaking.

It is right and just and, well, Canadian to think about how we can make Canada a better country for everyone. We must all continue to strive for decency, fairness, equality and fundamental freedoms for all of us. We must come to a fair solution to recognize how we have harmed the Indigenous people to our national shame.

However, this year on Canada Day, I will think of my patient.

I will think about how despite what has happened this last year, there is likely no other country on this earth where an immigrant from Pakistan could be given an opportunity as a child to work diligently and wind up as a small town family doctor. And where that same immigrant, could wind up with a patient from a time and place that held repugnant views.

Canada gave me an opportunity to succeed if I grasped it. But it also gave my patient an opportunity to learn, to grow as a person, to put aside old biases and hatreds. It gave him a chance to get to know other people, and realize we are all human. It gave us a chance to meet, and yes, to learn from each other.

This year on Canada Day, I will think about my patient…. I will think of my friend. I will think about what he taught me. I will think of what we must reclaim.

I will think about the promise that is Canada.

Tone Deaf CFPC Fails Its Members, Embarrasses Itself

Recently, in what seems to these old eyes to be an insulting, vindictive and offensive move, Canadian Family Physician, the “Official Journal of The College of Family Physicians of Canada (CFPC)”, published a hit piece on Family Doctors that only serves to further demoralize and dishearten a beaten down profession. I cannot fathom the amount of, what at best could be described as political naïveté, and at worst a disconnected Ivory Tower mentality that would be required to write such a venomous attack on those who actually pay money to keep their organization going.

Seriously, what was the CFPC thinking when they okayed Roger Ladouceur’s editorial, titled “Family Medicine is not a Business.”?? (I refuse to link to it as I don’t want it to get any more hits).

Truly, it’s not really an editorial, rather a massive litany of complaints against family physicians, while sarcastically suggesting “surely, it’s just gossip!”

What exactly are evil rotten family doctors doing according to Ladouceur? He suggests the CFPC has “heard stories” about family doctors not seeing patients in person and wondering how they can assess complicated patients. He has “heard stories” about doctors only calling patients at more lucrative times and abandoning patients with high medical needs. He has “heard stories” about family doctors “charging excessive fees” for services not covered by health insurance.

He ends off his purulent missive by blithely stating, “Family Practice is not a business.” Marie (“Let them eat cake”) Antoinette would have been proud of such a comment, dismissively heaped on the approximately 40,000 overworked family doctors in Canada.

There’s a lot to unpack in Ladouceur’s diatribe. First and foremost is the fact that despite extolling the virtues of evidence based medicine, the CFPC allowed an editorial to run that had, well, no evidence to back it up. The whole argument was based on “I have heard stories.” There are no numbers to back it up, no names of offending physicians, no statistics on how widespread these alleged problems are. Just gossip and innuendo based on what he has “heard.”

If you want evidence by the way, I can confirm that the OMA Board was told that based on OHIP billing data over 98% of family doctors in Ontario continued to work after the pandemic was declared. It is true that they are using a mix of virtual and in person visits, but given the need to social distance during these times, a mix is clearly the correct way to proceed.

Furthermore, the banal statement that “Family Medicine is not a business” is simply factually incorrect, and reveals a kind of ignorant, Ivory Tower mentality that shows a complete disconnect from the real world.

Let me be clear about this, I consider myself one of the lucky ones. My family has food on the table. We have a roof over our head. There is no danger of my car being re-possessed. I’m fortunate compared to the average Canadian and am extremely grateful to be in that position.

But while I genuinely enjoy seeing my patients (they’re a great bunch of people), I still have to pay my staff, order supplies, pay rent and utilities, ensure my computers are working properly, get payroll taxes paid, comply with labour legislation etc etc. In short, while we all hate to think about this side of things, Family Medicine has been, and will continue to be a business of some sort. That the CFPC would allow such an obtuse comment by Ladouceur to run, shows a wanton disregard, and, dare I say it, contempt for the many day to day issues that its members face.

Look, no physician likes seeing one of their organizations scold them (and certainly I will always push back when I see this kind of stuff happening), but I really have to wonder just how completely out of touch the CFPC must be to allow this type of berating in the middle of the biggest physician burn out crisis I have ever seen. Prior to the pandemic, 26 % of physicians were clinically burnt out, 34% were suffering from a degree of depression and over 50% reported some symptoms of the burn out. Exactly what do you think has happened to those numbers after the pandemic? Especially with physicians recognizing that even though we seem to be coming out of the pandemic, there is an overwhelming backlog of delayed care to address?

Yet amongst this backdrop, here comes the CFPC, not to try to find ways to support physicians or provide tools to help them be healthy so they can look after their patients better, but to berate, admonish and vilify them as a group. This is supposed to make things better??

The type of evidence free invective Ladouceur ran should never have been given any platform, much less a platform on an organization who’s mission statement includes advocacy on the part of the specialty of Family Medicine. Frankly, I’m embarrassed to be a member of the CFPC, though given the regulatory requirements to maintain my continuing medical education, I can’t resign from it.

If the CFPC really wants to help, they will pull Ladouceur’s screed from their magazine, and apologize to all 40,000 Family Physicians in Canada. Anything less will suggest complicity and sympathy with his views, and will contribute to Family Physicians losing confidence in the CFPC.

Conscience Rights are HUMAN Rights

Last year, I wrote a blog about Conscience Rights.  The motivation for the blog was the concerning move by the Ontario courts to “infringe on doctors’ religious freedoms.

I know, I know, the case dealt with whether physicians (and other health care providers) had the ability to refuse to provide a referral for situations where they conscientiously objected. Currently, the hot topic for this scenario is Medical Assistance in Dying (MAiD). And yes, the headlines simply said the request for an appeal of a lower court decision on granting physicians conscience rights was denied. I also know there was a lot of talk about the right of the patient to determine their own health care (which is of course must be respected).

But in the text of the initial ruling, the courts clearly and unequivocally admitted that they were infringing on doctors’ rights.

I made a Star Trek reference in my last blog on this issue. Hence, one would be appropriate here. It would seem the Ontario Courts were using the logic first uttered by Mr. Spock in Star Trek 2 – The Wrath of Khan:

“Logic clearly dictates that the needs of the many outweigh the needs of the few.”

But is that really the case here? Will patients be unable to access legal health care services, simply because physicians are able to keep their fundamental human rights? The short answer is no.

In Ontario, for a service such as MAiD, all a patient really has to do is call the MAiD co-ordination service, and they are guaranteed an assessment. A physician who gets a request for this service simply has to give a patient the 1-800 number to call. Heck, patients can even look the number up online and call themselves without asking their own physician.

In short, the service is readily available to those who want it. The needs of the many are not, in any way, shape or form compromised by Conscience Rights legislation. The Ontario Courts have therefore willingly infringed on the rights of a minority, on the basis of a false premise.

Let me also mention the reaction to my last blog on this issue. I had mentioned that in the near future, we would be facing many ethical dilemmas as a society. Not the least of these include new genetic treatments and therapies. Most physicians were supportive of my blog but some expressed concern that brining up genetic advancements was too extreme. One commentator even used the analogy that seemingly all twitter arguments degrade to – “…can’t compare asking for MAID to asking to revisit the Nazi eugenics movement

And yet.

Look what’s happening in the world.

In China, a group of scientists have inserted human brain DNA into monkeys. They state the reason for this is to study conditions like Autism. Jeez, have these people never seen Planet of the Apes????

As Elon Musk dreams of colonizing Mars, scientists are now actively looking at “tweaking” the DNA of people who wish to colonize Mars as a way to protect them from harmful radiation and microgravity. There is even thought being given to merging our DNA with tardigrades (weird microscopic creatures that can seemingly survive anything).

This s all in addition to work that is being done by companies like Neuralink (another Elon Musk organization) to develop brain implants.

Indeed, as Davis Masci pointed out last September:

“But thanks to recent scientific developments in areas such as biotechnology, information technology and nanotechnology, humanity may be on the cusp of an enhancement revolution. In the next two or three decades, people may have the option to change themselves and their children in ways that, up to now, have existed largely in the minds of science fiction writers and creators of comic book superheroes”

These aren’t some weird tabloid, National Enquirer type stories. There are real scientists actively doing this kind of work. The point being that protecting Conscience Rights is not just about MAiD, it’s about ensuring that on a go forward basis, peoples fundamental freedoms are not impugned in what promises to be the most ethically challenging time for science in human history. It’s about ensuring that people do not have to work on or accept for themselves, things that they find morally objectionable.

As a free society, we have always recognized certain inalienable human rights. It’s not just the right to free speech, assembly or vote. The Canadian Charter of Rights and Freedoms specifically mentions freedom of conscience and religion (see section 2). This was due in large part to a recognition that a diverse society is a stronger society and in order to protect that diversity, we must protect fundamental freedoms.

That’s where the judges erred last year. By infringing on the rights of a few, stating that by doing so they were protecting the right of many (which as I’ve shown above, isn’t even the case), the judges have damaged our society as whole, and made it easier to take away more rights from more people. They failed to realize that you cannot make a society stronger, or more free, by taking away the rights of a minority. You only increase the possibility of taking away more rights in the future.

As a society, we must be ever watchful for these infringements on our freedoms. To use another Star Trek quote, this time from Captain Jean-Luc Picard (nerd alert – TNG episode “The Drumhead”):

Vigilance. That is the price we continually have to pay.

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

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

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

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

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

What poppycock.

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

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

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

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

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

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

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

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

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

Shame on all of them.

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

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

Let’s Discuss the Astra Zeneca Covid Vaccine

The following blog is written by Dr. Anne-Marie Zajdlik, MD, CCFP. She is the founder of ARCH Clinic Guelph and Waterloo, Founding Director of Bracelet of Hope and Founder of the Hope Health Centre

Let’s discuss the AstraZeneca vaccine.  I am just going to give you some facts.  You can make your own decision about the AstraZeneca vaccine.

On March 29th,  Canada’s National Advisory Committee on Immunization (NACI) recommended provinces pause on the use of the AstraZeneca-Oxford COVID-19 vaccine on those under the age of 55 because of safety concerns. NACI’s priority is vaccine safety.   Their decision came after the European Medicines Agency ( EMA), Europe’s Health Canada equivalent, investigated 25 cases of very rare blood clots out of about 20 million AstraZeneca vaccines given.  On March 18th the EMA concluded that the benefits of the AstraZeneca vaccine far outweigh this risk if there is a true increased risk of the blood clots.

Most of these rare blood clots occurred in women under the age of 55 ( 18 out of 25).  Thus, NACI’s recommendation to halt the use of the AZ vaccine in this age group pending further review of the ongoing real-time research.

So, 25 cases out of 20 million vaccinations is a risk of about 1 in a million.  That means that if there actually is an increased risk, the risk is 1 case of the rare blood clots out of 1 million vaccines given. One in a million.

Let’s shed some light on that: The risk of blood clots developing among new users of oral contraceptive pills ( birth control pills) is 8 out of 10,000. Thirty four out of 10,000 women who use  hormone replacement therapy ( HRT ) will develop a blood clot at some point.  And, the risk of developing a blood clot in women in general  is is 16/100,000. 

The Canadian maternal mortality rate ( the rate of death in women during childbirth) is 8.3 deaths per 100,000.

No medical intervention is without risks.  The question is, should we take that risk?  That is what NACI will try to figure out in the coming weeks. Let’s balance that risk of 1 in a million with the risk of COVID-19. 

A new briefing note from a panel of science experts advising the Ontario government on COVID-19 shows a province at a tipping point. Variants that are more deadly are circulating widely, new daily infections have reached the same number at the height of the second wave, and the number of people hospitalized is now more than 20 per cent higher than at the start of the last province-wide lockdown.

These variants are more dangerous and more easily transmitted.  They cause 2.5 to 4.1 deaths per 1000 detected cases.  That’s deaths.  The risk of serious complications with the variants is double the risk of the original COVID-19 virus:  20 out of 100.

Here’s a quote that scared me.  “Right now in Ontario, the pandemic is completely out of control,” Dr. Peter Juni, the scientific director and a professor of medicine and epidemiology with the University of Toronto and member of Ontario’s COVID-19 science advisory table.

The AstraZeneca vaccine is over 70% effective up front and almost 100% effective at preventing deaths and hospitalizations from COVID-19. Breathe.  It is not time to throw out the baby with the bath water.  No blood clots have occurred in people over 60.  We should continue using the AstraZeneca vaccine in this age group which is most at risk of serious complications and death from COVID-19.

Open Letter to the Emergency Operations Centre

I wrote this email on March 23, 2021 to the Emergency Operations Centre of the Ministry of Health in regards to Directive #3 which places significant restrictions on the residents of Long Term Care homes during the pandemic. The email has gone unanswered and so I making it public today.

Hi there,

I’m currently the medical director for Bay Haven Long Term Care in Collingwood Ontario.  I had sent the email below asking for some easing of restrictions for our LTC as we now have all but two residents (new admits) who were fully immunized for COVID-19.  Our medical officer of health, Dr. Colin Lee expressed that while he was sympathetic, he could not overturn Directive #3, and asked that forward you with my original email.  I would ask that you please consider the overall well being of the residents in LTC centres like mine, where we have almost full immunization.


Begin original letter:


Hi Xxxx, 

I understand you are the contact person at Public Health for Bay Haven.  I’m hoping that you can help me advocate for the residents of the nursing home.  As you are aware, most nursing home residents throughout the province are suffering from “confinement syndrome”.  The year long isolation caused by the COVID pandemic has had a devastating effect on their emotional health and the residents are really struggling as a result.  

As the Medical Director, I see these issues when I visit, and it pains me to see how much the mood of the residents has gone down in the past year.  Don’t get me wrong, I do understand the rational behind some of the restrictions that have been put in place, and I have supported those restrictions.  They were important to protect the health and safety of Bay Haven, and we have been fortunate to not have a COVID outbreak in our facility. 

But we also now are in a situation where all but two of the residents (new admits) are immunized for COVID and a good number of staff are immunized as well.  With that, I need to focus on the other aspects of care for the residents.  

The blunt reality however, is that Bay Haven will not go against Public Health directives, no matter what I personally think of them.  So I need your (or somebody in public health’s) support to change some of the directives. 

I want to point out that the most recent data shows that the COVID vaccines DO, in fact, reduce transmission (https://www.nbcnews.com/health/health-news/pfizer-covid-vaccine-cuts-transmission-coronavirus-new-real-world-study-n1260542).  This is unsurprising as every other successful vaccine also reduces transmission, but we now have proof of this.  In fact, transmission of COVID is reduced after just ONE dose of the vaccine (https://www.huffpost.com/entry/pfizer-covid-19-vaccine-reduces-transmission-after-1-dose-study-finds_n_6038e92ec5b6b745c4b655ba). 

With that, I would like to implement the following changes (and need Public Health to support): 

1) We continue to have less than 100% of our staff immunized.  To encourage more of them to be immunized, I would like to stop screening with np swabs, those that have been immunized (two weeks after their second shot).  Nobody likes getting an NP swab.  If the un-immunized staff see that they will not be subjected to this test, it might encourage them to get their own shots.  And we get to save our swabs for those who really need it.  (Addendum – Since this letter is public, what I was not aware of when I wrote the original is that Bay Haven actually has one of the highest percentages of nursing home staff who’ve been immunized in the province – almost 80%! Having said that, nothing wrong with going for the other 20%)

2) All the residents who have been immunized need to be allowed to go back to congregating as usual.  This includes all their group activities and sessions. 

3) We should allow an increased number of visitors to the facility.  I would agree the visitors should have proof of either immunization, a recent negative COVID swab, or be willing to have a rapid swab done in our facility.  I think each resident can assign 4 people who can come and visit, and we can work on putting a limit on the number of visitors at any one time.  

4) If a resident has been immunized, they should be able to leave the facility for social gatherings, not just medical appointments.  Whoever drives them would need to have proof of immunization, a recent swab or have an NP swab in our facility since they presumably enter the building.  But the immunized resident cannot (as per the articles above) bring back and transmit the infection themselves. 

If Public Health could support this, it would go a long way to improving the mental health of the residents and improve their quality of life.  It’s the least we can do after all they have done for society over their years.   

Sohail Gandhi, MD, CCFP

Medical Director, Bay Haven Seniors

Alberta Doctors Should Reject the Tentative Agreement

Disclaimer: Just a reminder that, once again, I am not speaking on behalf of the Ontario Medical Association. The opinions expressed in this blog are mine, and mine alone.

Many who read this will wonder why I’m talking about a potential physicians agreement in another province. Some will point to my role at the Ontario Medical Association (OMA) as past-president and suggest that I should stay out of the affairs of another Provincial, Territorial Medical Association (PTMA). Normally I would. But the situation in Alberta has implications for physicians across the country, including Ontario, so I feel compelled to speak out. Besides, considering the then President of the Alberta Medical Association (AMA) commented on our own tentative agreement in 2016 (and he was right by the way), I think it’s ok for me to speak out as well.

I don’t know all the details about the ins and outs of how the AMA works, nor do I know all minutiae about their negotiations process.

But I know when doctors are getting screwed by a government.

Alberta Health Minister Tyler Shandro

Last week, the Alberta Medical Association (AMA), announced a tentative agreement with their government. The agreement allows their volatile, combustible Health Minister Tyler Shandro almost unlimited, and truly unprecedented power over Alberta Physicians:

  • It reduces their physician pay to 2018 levels
  • It gives the temperamental Shandro Ultimate authority over how much physicians get paid. Just read this truly scary statement by the AMA:

“The AMA acknowledges that the physician services budget is established by the minister in the minister’s sole discretion,” it states.

“The AMA further acknowledges that nothing in this agreement fetters the minister’s authority or discretion with respect to the physician services budget.”

  • It places a hard cap on the physicians services budget, meaning that if the demand for care went up above the predicted level, physicians incomes would be clawed back to make up the difference. As an aside, demand will almost certainly exceed the projections. We are coming out of a pandemic and are facing an enormous backlog of care. How eager do you think the volatile Shandro will be to allow an overage of the physicians service budget going forward?
  • Worse, the AMA is required to discontinue their lawsuit demanding binding arbitration, which all physicians should view as an inherent right.

For me personally, the whole Alberta situation has brought back some particularly bad memories. In 2012 the OMA accepted a 0.5% fee cut in the hopes that appeasement of a bullying government would lead to better things in the future. This of course is not the way to stand up to bullies, and Ontario physicians felt the brunt of this as the now second worst health minister I have ever seen, “Unilateral Eric” Hoskins, sensing weakness, imposed unilateral cuts to physicians in 2015.

After a couple of years of internecine warfare, the OMA and Unilateral Eric came to a tentative agreement in 2016 as well. That agreement:

  • Reduced physicians pay to levels from a few years back setting a lower base rate for the Physician Service Budget
  • Allowed for a hard cap on physicians billing
  • Allowed the Health Minister to claw back physicians billings if usage exceeded projections

Sound familiar? At least the Ontario agreement allowed our own Charter Challenge on Binding Arbitration to continue (which it painfully, slowly does to this day).

We were told by the OMA Board at the time that this agreement was the “best that could be done” and that we were going be faced with even more clawbacks and cuts if we turned it down. As is well known now, the agreement was soundly rejected, the increased clawbacks never materialized and when faced with the prospect of an election, the government of then Premier Kathleen Wynne finally had to recognize that Arbitration was an inherent right for all essential workers, physicians included, and we secured a fair Binding Arbitration Framework.

All of which is my way of encouraging Alberta Physicians to realize that they don’t have to simply roll over and accept the “best we can get”. While there will be some pain in rejecting the agreement, at the end of the day, governments need to go to the polls. That’s when having angry doctors makes them vulnerable. It will not be pleasant to hold out, and say no (it certainly wasn’t in Ontario!) but I submit that it is better to keep your integrity intact and stand up to a patently unfair deal.

But wait, what about these implications for physicians across Canada I referred to? It all has to do with negotiations.

Obviously, I can’t talk in detail about negotiations. BUT, what I can confirm is what many of us have long suspected. Bureaucrats from Provincial Governments talk to each other all the time. They share data. They share information, and they share tactics. They may or may not (depending on their political masters) use a particular tactic/program/scheme etc, but they do share.

Which means, that IF Alberta docs pass an agreement like this, which chains them to a hard cap and allows even a minister as incendiary as Shandro, free, unfettered reign, then we can expect other governments to attempt this as well. “Your colleagues in Alberta accepted this, why can’t you be as reasonable and co-operative as them?”will be the opening position in negotiations in many provinces after this.

That is why physicians across the country should follow the situation in Alberta with interest. That is why we should support our Alberta colleagues. That is why, for the sake of physicians in Alberta, and everywhere in Canada, this deal needs to be rejected.

If you want more, a colleague has prepared a helpful Q&A about our situation, and you can access it here.