Nightmare in Thunder Bay

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 story at Medium.com

“Smokey” Thomas Fails His Members

Authour’s Note:  Once again, I would like to state that while I am President-Elect of the Ontario Medical Association (OMA), I have not spoken with any of the Family Doctors in Owen Sound about this situation.  I did email them to ask permission to write this.  All of my thoughts are strictly based on reports in the media, and news releases (all of which are hyperlinked).

Last week I had suggested that Ontario Public Services Employees Union (OPSEU) President Warren “Smokey” Thomas should change his approach on how he dealt with physicians in union disputes.  Sadly, Smokey has doubled down on his tactics.  In doing so, not only has he utterly and completely failed his members, but he risks endangering health care in Owen Sound.

In Owen Sound (population ~ 21,000) there are 22 family doctors who have organized themselves into a Family Health Organization (FHO).  The FHO is a fairly common payment model that consists essentially of a salary and performance bonuses.  Like all other payment models the FHO models experienced years of deep cuts to their budgets during the desultory tenure of Premier Kathleen Wynne.  Cuts to physician payments, mean cuts to patient services.  Hence, the FHO focused on controlling expenses as best it could.

The staff at the FHO chose to unionize (which is their right) but unfortunately chose to do so under OPSEU, and became Local 276.  OPSEU and Smokey have absolutely no experience in dealing with intimate small office settings, and the necessary collegiality that is essential to providing high quality front line care.  As a Family Doctor, you MUST trust everyone from the receptionist, to the nurse and even the cleaning staff.  While disagreements occur, and are often healthy, the trust cannot be compromised, or patient care will suffer.

Smokey and OPSEU’s lack of experience showed almost immediately. Their bargaining team agreed to a contract and recommended it for approval to the FHO staff in May.  That’s right folks, OPSEU actually reached an agreement.  But the agreement was rejected by the FHO staff, a clear repudiation of OSPEU’s leadership.

This appears to be when Smokey went off the rails.  He (and OPSEU) could have taken a hard look at themselves and asked a simple question – “How could we be so out of touch with the members we represent, to have endorsed a deal they rejected off hand?”. But they didn’t.  Instead, in what seems to be an effort to prove to their members that they really are relevant, they doubled down and started hurling insults and threats.   Doctors were “punch drunk with greed” they screamed.

The FHO staff then went on strike, and the results appear to be disastrous for them.  Firstly, OPSEU should have told them that doctors office are not factories that make sprockets and cogs.  They provide essential medical services and they cannot be shut down.  The physicians continued to work, with legally allowable replacement staff (albeit at reduced levels).  All a picket line would do is harass patients, and that won’t win you public support.

Reports of harassment and even a serious medical event involving a replacement worker appeared, although it’s unverified.  Again, instead of stopping to think “What exactly are we accomplishing here?” Smokey, doubled down, increased his insults to physicians, demanded that the Health Minister and Owen Sound Town Council get involved (he failed miserably).  He also made a ludicrous allegation that physicians were “private and for profit”. Has Smokey not read the Canada Health Act?  Physicians haven’t been private since 1984.

Apparently, ten of the 30 FHO staff got wise to what a lousy job Smokey and OPSEU were doing, and actually quit their jobs.  Yet another opportunity for OPSEU to reflect on their own failures as a bargaining agent.  But yet again, Smokey lashed out, this time by asking the College of Physicians and Surgeons of Ontario (CPSO) to get involved.

Let’s be clear, the letter written by OPSEU is a collection of hearsay without naming any one physician. As such, it cannot possibly be investigated by the CPSO.  If they were to do so, it would diminish the already poor standing the CPSO has in the eye of most physicians, and would send a pall over the entire profession. They would almost certainly faced increased calls from physicians to lose self-regulation if there was anything other than a cursory “thank you, but this is outside of our purview” type response.

But the reality also is that a letter to regulatory body like this takes you beyond any hope of restoring trust in your team.  It’s the one thing that has potential to destroy careers. It’s the one action that essentially screams “irreconcilable differences”.  By going down this road, in what seems to be a desperate attempt to prove his worth, Smokey has caused a toxic meltdown to the point where there is no hope of a resolution.

The members of OPSEU Local 276 would do well at this point to really ask themselves if this is the kind of leadership they signed up for.

Nothing Wrong With Advocating For Physicians

Authour’s note:  This opinion piece of mine was published in the Medical Post.  However, many physicians are unable to access that as you need a dedicated account.  I’ve reproduced it here.

The Canadian Medical Association (CMA) has been embroiled in controversy this past year.  It first started with the announcement of “Vision 2020”, the new strategic plan for the CMA. What’s the first priority of the plan? “Consistently bring a patient perspective to the work of the CMA.”  The second priority?  “Engage in courageous, influential and collaborative dialogue and advocacy.”

This all sounds nice, and politically correct and oh so socially conscious.  Except for one thing.  The CMA is supposed to represent physicians and their needs.  That’s the whole reason for its existence.  Instead, physician representation is third on the priority list, and even there, it’s couched in phrasing like “based on empowering and caring for patients, promoting healthy populations and supporting a vibrant medical profession.”

From the perspective of the CMA’s leaders, I suppose the needs of the general membership don’t really matter.  The recent sale of MD management to ScotiaBank has provided the CMA with a significant amount of revenue.  So much so that they likely don’t even need members anymore.  It’s worthwhile noting that the first $15 million from the sale has been earmarked for a building for health care innovation, as opposed to, you know, a program to look at the alarmingly high burnout rates of physicians.  Certainly the changes made at CMA Governing Council (no more motions to direct the organization) prevent the CMA Board paying attention to silly little things, like the duly elected representatives of physicians across the country.  (NB – it would be unfair of me not to acknowledge that at least the General Membership will be able vote on all the Board members for the CMA.  However, I’m curious to see what the criteria are for becoming a candidate for CMA Board).

There is similar pressure to advocate for patients and health care policy, being placed on the Ontario Medical Association (OMA), particularly on social media.  Recently the OMA has been asked by various physicians to:

– sign letters opposing the separation of children from parents of migrants

– condemn the changes to sexual education curriculum made by Premier Doug Ford’s government

– speak out against the pause to Vaping rules, also made by Doug Ford’s government

– express concerns about the health care for trans gender patients

– and a bunch more.

There are merits to all of those causes (the separation of children from parents is the one I feel strongest about – it’s just child abuse). There is also the argument that physician’s organizations should use their authority to advocate for social issues, as it increases our standing in the eyes of the public and makes us “leaders”. This enhanced standing will supposedly help us when we advocate for ourselves.  The cynics, especially those of us burnt by the previous Ontario government will strongly disagree with this.

But here’s the thing, there are so many good causes out there to advocate for.  And they will keep coming.  How should the OMA, which unlike the CMA, continues to need broad member support, choose?

There is already disagreement about vaping rules/sex ed curriculums and so on.  What happens when the OMA is presented with information about the poor health care Rohingyan women receive?  Or the damage the contaminated water in Flint Michigan has caused?  Or if you want controversy, how about the malnutrition and mental health issues suffered by Palestinian children?  The OMA is supposed to represent 40,000 members with a diverse range of views, not just those who are motivated by one particular issue.

Many Provincial and Territorial Medical Associations (PTMAs) offer media training and advocacy courses.  The OMA for example, has long been asking physicians to become advocates.  Perhaps rather than criticizing on social media, those who feel passionately about various issues can receive the training to allow them to become leaders in their areas of interest.  They can then directly get their message across to the public and work for whatever their cause is.  They are still doctors, and they will still be seen in the public’s eye as doctors taking a lead on health care issues.

As for the PTMAs is it really too much to ask that they focus on membership advocacy first and foremost?  There is absolutely nothing wrong with advocating for meaningful action on high burnout rates, fair contracts and improved working conditions with less interference from bureaucracy.  It’s what these organizations are supposed to do.  The simply reality is that you cannot have a high functioning health care system without happy, healthy and engaged physicians.  Surely advocating for the same is not unreasonable.

Smokey Should Put Out Fires, Not Start Them

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.

 

 

 

Why Universal Pharmacare Is Doomed

“Hell hath no fury like a bureaucrat scorned.” – Milton Friedman

First, let’s get something out of the way.  I support the concept of Universal Pharmacare. From a basic human standpoint, I’ve seen many patients who cannot afford prescription medications go without them. It’s awful to see their health deteriorate when treatment could have been available.  Providing a social safety net is part of the Canadian ethos.  It’s almost un-Canadian to not have Pharmacare when places like Australia and pretty well all of Western Europe have it.

From a purely fiscal point of view, Pharmacare makes even more sense.  People who develop complications from untreated illnesses cost the health care system much more. Additionally, there are significant cost savings because a Canadian Pharmacare program will allow for bulk purchasing of drugs, which lowers costs.  It will also reduce the cost of running a business in Canada, thus helping the economy.

Currently Health Care is considered to be a Provincial responsibility,  and every Province has its own Drug Benefit Program for seniors and those on social assistance. Which of course means that each Province has their own formulary (the list of drugs that are covered by the provincial drug plan) and there are some differences. Ontario, for example, doesn’t provide coverage for some of the newer Cancer drugs that many Western Provinces do. Having a Canada wide formulary will mean we can fix these regional discrepancies and provide equitable treatment for all Canadians.

But if it Pharmacare is such a great idea, why is it doomed to failure?

For the same reasons that so many good ideas die in Canada – politicians and bureaucracy.  You see, politicians can’t see beyond their next election cycle, and their need for votes.  Bureaucrats can’t see beyond the need to perpetuate their own organizations and protect their own jobs.  It’s a toxic combination that has vexed health care in Canada for decades.

To understand this, let’s look at what should happen to make Pharmacare a success.  The federal government should come up with a Canada wide formulary.  This part shouldn’t be too hard; there are likely many commonalities between the varying Provincial formularies, and coming up with a list of necessary drugs should be easy.

Then the Canadian government should form a central agency, to negotiate a price and pay pharmaceutical companies for these medications.  In essence, Ottawa should take over the role of the Provincial drug formularies and establish one Canada-wide plan.

In order to pay for this, the Canadian government should reduce transfer payments to the Provinces by the amount of money they spend on their own programs.  Ontario currently spends $4.2 billion dollars a year on its Drug Benefit program.  So clearly, what the Canadian government should do is say to Ontario – “Look, we’ll take over the drug benefit program, you close down yours, and we will cut your provincial transfer payments by $4.2 Billion per year, since you don’t need it anymore.” And there’s problem number one. How do you think that will go over with the cash strapped government in Ontario?

From a politician’s point of view, they are going to risk angering the bureaucracy because this means there will be less jobs – economies of scale mean you need fewer people to run one big organization, then ten smaller ones.  This means the various civil service unions will be up in arms about closing the Provincial Drug Benefit programs. Granted upsetting bureaucrats probably won’t bother Ontario Premier Doug Ford as he has already signalled that he is going to reduce bureaucracy, but Prime Minister Trudeau (especially given his recent falling popularity) is likely going to want all the votes he can get.  Civil servants still donate to political parties – and he will not want to anger them.

Now if you have a strong-willed leader of your Pharmacare strategy, you can probably still make this change.  But alas, Trudeau hired the widely disliked and ineffectual Eric Hoskins to lead this program.  Hoskins’ main claim to fame is his utter and complete failure as a Health Minister in Ontario.  As predicted, he didn’t survive the disaster he made of Health Care.  It’s clear he jumped at the chance to get a cushy taxpayer paid job, as he knew he was going to lose his own riding of Toronto St. Paul (which was supposed to be one of the safest Liberal ridings in the Province).  His hiring does NOTHING to engender confidence that an effective Pharmacare program is possible.

What will we likely be left with?  Probably some sort of hybrid system.  This will be promoted to be in “the interests of recognizing regional diversity”.  Ottawa will create an agency to provide “oversight” and purchasing of a certain list of medications.  Then the Provinces will keep their own agencies, and buy the drugs via Ottawa. If you happen to need a drug that isn’t on the approved list, you can apply for an exemption to the Province (this part exists now).  But then the Provinces will likely turn you down and then you have to apply to Ottawa.  Goodness knows how much paperwork will be involved, and how many delays.

The end result?  TWO layers of bureaucracy for National Pharmacare, more civil service jobs, more money (and time) wasted on Provincial/Federal interplay.  How will this help?

Pharmacare is long overdue.  I just wish our politicians had the guts and foresight to implement it in a reasonable, efficient, businesslike manner.

Can Helen Angus Save Ontario Health Care?

Health Care in Ontario has been in a state of crisis for many years now. I’ve practiced Family Medicine for 26 years, and I’ve never seenwait times so long, nor have I seen such a dismal moodamongst health care providers. Clearly, a major transformation of how health care is delivered needs to occur.

Ten days ago we saw a new government in Ontario. By glancing at twitter feeds and media reports, the biggest news in health care seemed to be about the appointment of new Health Minister Christine Elliott. Minister Elliott is an excellent person and will bring the kind of common sense to the Health Ministry that was completely absent during the Kathleen Wynne/Eric Hoskins years. BUT, the most important announcement last week (and one widely ignored by the media) was actually that of Helen Angus to role of Deputy Health Minister. She takes over for the widely dislikedBob Bell, who suddenly retired once the Liberals lost the election. Curious timing that retirement, considering the post is supposed to be apolitical.

You see, the Health Minister is the person who produces high-level strategic directions for health care service delivery. But it’s the Deputy Minister who actually carries out the grunt work and implements the processes to carry on these strategic directions. Having been part of many organizations, I’ve seen bureaucrats both greatly benefit – and greatly hinder – the implementation of these strategic directions. It will be up to Ms. Angus to do the heavy lifting, and transform the Health Care system.

Is she up to it? Her bio shows she has been heavily involved in health care for many years, including various roles at the Ontario Renal Network, Cancer Care Ontario, the Ministry of Health and others. She was actually the interim Deputy Minister of Health for five months, until the aforementioned Bob Bell was hired. Then she suddenly left the health care field altogether to help out the Ministry of Citizenship. (More curious timing there). So with that experience there is a sense that she will bring a steady hand to the position.

Based on her speech to the “Breakfast with the Chiefs” she also has the ability to “speak the language” of health care bureaucrats. Phrases like “shared accountability”, “transformation secretariat”, and “stream of work” fluidly roll off her tongue. Personally, I find these phrases vapid and incomprehensible (eHealth Ontario for example is not “still a journey” as she states, it’s a disaster). However, this kind of verbiage is needed to communicate with other health care leaders, so I’m glad that she is able use it.

What does she truly believe in as far as health care goes however? Assuming she wasn’t just towing a political line, it also appears from her speech that she recognizes the need to transform health care and break down the various silos in health care. Silos refer to the fact that we have a bunch of different organizations in health care, e.g. hospitals, home care, your doctor’s office, that operate independently, and often not in a co-ordinated manner.

When I was the Health Links lead physician for South Georgian Bay, I recall Deb Matthews referring to Ms. Angus as “the silo-buster”. Ms. Angus of course, never got to work on that because as mentioned, she suddenly left health care altogether when Bob Bell became the Deputy Health Minister. Bell, under the guidance of the pitiful Eric Hoskins and the forlorn Kathleen Wynne never got around to busting silos. Instead the three of them thought it would be better to get into a toxic, pernicious, and vexatious relationship with Ontario physicians. We all saw how that worked out.

Ms. Angus spoke of the need to make health care more patient centred, and improve access for patients. Part of that will require a significant streamline to Ontario’s bloated health care bureaucracy. Part of that will require she forces a dollop of common sense down her bureaucrats throats (why does it take two years to make a change when everybody agrees something is a good idea?).

The good news is that she appears to have some cover in that current Premier Doug Ford wants to run a fiscally responsible government and reduce bureaucracy (though by natural attrition as opposed to layoffs). More good news is that the Ontario Medical Association (with whom she must partner if any transformation is to occur), recently decided to temporarily suspend the arbitration process they are involved in, in order to hear the new governments position. As a gesture of good faith, they didn’t even ask for a concession for this move. If she can help to repair the noxious relationship created by the Liberals, and give doctors a meaningful say in how health care is delivered, she will be able to move more effectively in her goals.

It’s a big job ahead for her. For the sake of all Ontarians I wish her well. Our health care system is too important to be allowed to flounder any longer.

Good company in a journey makes the way seem shorter. — Izaak Walton

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