What Backlogged Health Care Looks Like and How to Fix It.

Dr. Silvy Mathew guest blogs for me today. She is hands down one of the smartest people I know. She writes about her experience in visiting the ER to help a family member. Dr. Mathew has been a strong advocate for health system reform and it is a loss for all Ontario residents that her warnings about the impending crisis in health care were not heeded by Health Ministers dating back to Eric Hoskins.

A few days ago I was in the Emergency Room (ER) with a family member. The ER was slammed. The paramedics were lovely and about four teams that I could see were stuck in waiting room, waiting for their patients to be triaged. We were on a stretcher by the front sliding doors. Almost outside.

We were there for urgent imaging, and possibly consultation. We tried to do this in the outpatient setting, but lack of access to both urgent images and consults for urgent care makes that impossible. So we go off to ER by EMS (needed for transport).

I’m fortunate. I am able to fill in gaps. I can advise triage what issue is, as they can’t do physical exam in the waiting room in front of what seems like hundreds of people. I can provide medical information on relevant questions. I can monitor the patient status for changes.

I did remind staff after several hours to check blood sugar as my relative is an insulin dependent diabetic, now off food/fluids. I did remind about necessary medications to be given. Of course, if I wasn’t there, they may have reviewed the chart closer but they were clearly slammed and trying to manage.

And we weren’t in distress. My family member was unable to advocate for themselves. We got imaging about six hours in, and I watched the imaging staff, working with 50% less nursing staff, literally just running in and out moving people. Doing their best.

We had excellent care from people busting their butts. But so many potential falls through the cracks and errors. Twelve hours later, we got home, luckily without any new issues from ER. And we had a plan. And we had a specialist who called first thing in the a.m. to ensure we have close follow-up.

The system in Ontario has relied for decades on individuals and work-arounds making things work (like above) when the system design is archaic. Successive Ontario governments have refused to participate in strategic multi-pronged co-design, instead of piecemeal band-aids.

I have worked for 15 yrs in Ontario health care. I’ve witnessed how far things have fallen and how none of our work arounds previously used are available now after the Covid 19 pandemic, for multiple reasons. I’ve participated with the Ontario Medical Association and sat on bilateral committees with the government to try to advocate for system change.

I’ve witnessed how siloed and unaware most people outside of primary care are. Family Medicine is the canary NOT the Emergency Department. The issues that have caused this system collapse have been occurring since 2012. Many of us, especially Dr. Nadia Alam, tried to be loud and warn.

Last year, in 2021, we gave up. It was obvious to us it was too late. We heard for years from our mid-career colleagues about how they couldn’t do this anymore. How they wouldn’t work in a system that didn’t allow them ANY joy or success while taking more and more from them personally.

Covid-19 just pushed the dial a bit faster. The family doctors who were hanging on from retiring have chosen to live now (not leave, but LIVE). The mid-career family docs are struggling as mentioned above and also choosing to leave family medicine if possible, because nothing is working in it. Obviously, new graduates are terrified.

And so here we are, and the CCFP answer to this is to ADD a third year to residency. Because somehow they think adding more school, asking people to take on more debt, delay starting their lives longer, while having less non-academic preceptor support will somehow help?

What it will do is: add even more fuel to the family medicine crisis and shortage. It’s not gonna teach you how to run a business (last I checked real life experience mattered more). It’s not going to teach how to manage complexity in real life. It WILL drive more people out of family medicine residency.

What we REALLY need is a re design of the health system. You want people to do this job? LET them. You want family doctors to work at the top of their scope? ENABLE them. Support access to resources OUTSIDE of hospital and provide help to coordinate.

Stop advocating for more debt and school CCFP, and advocate for real life mentorship, group practices and shared care. You want Emergency Rooms to not house people? Fund home care and long term care. Fund resource teams to support those in seniors neighborhoods already. Use a community approach.

While we are at it, stop spending all the money on pharmacology. Fund allied health, encourage exercise programs and healthy meals because that’s WAY more useful than the hundreds of thousands of dollars of Botox we spend on contractures AFTER they occur. Keeping people mobile keeps them out of hospital and long term care.

The Canadian media can stop asking if health care has collapsed, anyone working in it knows it has. It will show in a year or two, when the numbers of late-diagnosed cancers, life expectancy and other markers of care get affected. But in real-time we are seeing it now.

If we don’t have some real leadership here and some true innovation, we are in for some truly sad times in the next decade. End.

All Ontarians Should Hope New Health Minister Sylvia Jones Succeeds

New Ontario Health Minister Sylvia Jones

Sylvia Jones is now Ontario’s Minister of Health, the largest, most volatile ministry in government. The Ontario Medical Association’s (OMA) correctly tweeted about this:

My first thought when I saw this was a somewhat flippant “should have sent her condolences instead.” Minister Jones has a whole lot of headaches going forward. To succeed, she pretty well needs to be perfect. A cursory glance at the issues she faces is mind boggling.

Should she support further lifting of Covid-19 restrictions? This will make some doctors mad. Should she instead support re-introducing mask mandates and tightening of Covid-19 policies? This will make other doctors angry. Worse, both sides have credible experts, so the whole “listen to the experts”can’t apply when the experts themselves are saying different things.

There is a Health Human Resources crisis unfolding in Ontario (and Canada). Hospital ERs are being closed due to staffing crises and there does not seem to be a quick solution. As more health care workers plan on retiring or leaving the profession early, finding replacements is going to be exceptionally challenging.

The Long Term Care (LTC) situation is equally dire. Wait times for LTC beds in Ontario are skyrocketing. In 2017 I wrote about how we needed 26,000 hospital beds right away, and another 50,000 by 2023. More beds are being built by the Ford government, which is great, but they will take time to arrive.

A quick solution to ease the burden would be to allow older homes who had ward beds in their facilities, open them up again. Rules were changed under covid to no longer allow 4 residents per room. However, if you do that, people will scream you are committing gerontocide. (This is despite the fact that just about all residents in nursing homes have got four covid shots now).

Need more? (As if that wasn’t enough). Over 20 million medical procedures were delayed due to the pandemic. Many of these procedures are early detection screening tests for cancer (sooner you catch, the sooner you cure and, cold-heartedly, the less cost to the health care system).

How about wait times? Wait times for medically necessary procedures continues to rise. MOH bureaucrats like to refer to these as “elective” procedures. But the reality is that if you are suffering from knee pain every day, and have to wait a year to get a knee replacement, it’s not elective, it’s necessary.

All of which makes me realize just how courageous Minister Jones is to take on the Health Portfolio. Allah/God/Yahweh/(insert deity of your choice) knows I wouldn’t want the job. But if I may, I would suggest the Minister should focus on a few things in the first year, as even improvements in a couple of areas will have benefits across the health system.

A word of caution first. She should take what bureaucrats tell her with a grain of salt. There were a few times when I was on the OMA Board when it became obvious that the MOH Bureaucrats had NOT fully informed then Health Minister Christine Elliot about some issues around physicians that caused needless kerfuffles. The bureaucracy has a certain way of thinking that is rigid, ideological and focussed on self perpetuation as opposed to making meaningful change.

I don’t always agree with columnist Brian Lilley of PostMedia, but he hit the nail on the head when he wrote:

“…Ford and his team shouldn’t rely on the Ministry of Health for solutions. These are the people who got us into this mess and who have been failing upward for years..”

and

“..Ford has a real opportunity to change health-care delivery, to speed up access to services, to do away with wait lists and all without changing the single-payer system that Canadians rely on..”

The last comment lines up nicely with the first part of the OMA’s Prescription for Ontario, where they recommend developing outpatient surgical clinics to move simple operations out of hospitals and free up beds. The bureaucracy will oppose it because they are incapable of new ways of thinking and are beholden to hospitals. But at least the Minister will have the support of Ontario’s doctors to work through some of the blowback (there’s always blowback to anything new).

The other easy win is to develop a digitally connected team of health care providers for each patient (also an OMA recommendation). We have something similar in the Georgian Bay Region for the past 12 years and I cannot stress how much it has improved patient care. If I have a patient in need of increased home care, all I have to do is message the home care co-ordinator directly from their chart and ask for help, and they usually respond within 24 hours among other benefits.

This also ties in with a project I was pushing hard for during my term on the OMA Board that got sidetracked mostly by the pandemic but also with some political issues around OntarioMD. I remain convinced that had that project gone forward there would be people alive today that aren’t because of the improved communication it would have provided. But at least preliminary work on it has been done, and with a nudge from the Health Minister this could potentially be restarted to give patients a digitally connected health care team.

NB- this is another area where the Digital Health Team at the Ministry of Health is going in the wrong direction. Their plans are (in my opinion) needlessly complex and won’t result in the kind of robust digital health infrastructure that is absolutely essential to a high performing health care system.

In short, Minister Jones has a monumental task ahead of her. Someone will will criticize her no matter what choices she makes (it’s no secret that health care is referred to as the third rail of politics). If however, she can set, say, three attainable goals in her first year (my suggestions would be open LTC beds, start building outpatient surgery clinics and get the digital infrastructure done), while keeping the bureaucrats in check, then real progress can be made in improving the health system.

All Ontarians, regardless of political stripe, should hope she succeeds. Our crumbling health system depends on it.

It’s Time to Open Up Nursing Home Capacity

Recently, I posted what I referred to as a controversial tweet about the need to open up nursing home beds that had been closed during the seemingly never ending Covid pandemic.

While there was not much “controversy” in twitter feed as a result of this, it did lead to some questions being asked during an interview I gave for CTV News.

While I certainly appreciate the professional nature of the reporter (the always adept Kraig Krause), the reality is that 30 second blurb on this topic, in an interview about all things COVID, can’t really do it justice. So let’s delve into this deeper.

It’s no secret that Ontario’s Nursing Homes were hit hard by the Covid pandemic. One nursing home in my region, Roberta Place in Barrie, was ravaged badly by the disease. I still grieve for all of the residents and families there, including those who survived as they likely continue to suffer some of the after effects of what transpired.

In the wake of these and other such stories, the Ontario government quite correctly limited the number of residents in ward beds at nursing homes. Many of Ontario’s nursing homes are very old buildings. The nursing home I’m honoured to be a medical director for has great ownership (private as it happens) and great staff, but the building itself if 52 years old and would not meet newer, more modern standards for nursing homes.

When my nursing home was built, having a ward bed (four residents to a room) was thought to be reasonable. Given that Covid is airborne (like most other respiratory illnesses!) the COVID19 Directive #3 (linked above) for nursing homes limited the number of residents to two per room. This made perfect medical sense at the time, and I certainly supported it then.

The reality however, is that health care is not limited to a single disease. We do have Covid of course, but we have a whole lot of other illnesses that we need to deal with. The Ontario Medical Association has estimated that a minimum of 16 million visits or procedures have been delayed as a result of the pandemic. We can’t keep delaying these. We need to address all the other health care issues that Ontarian’s have, and not just maintain sole focus on Covid.

Right now, I personally have two patients who are in hospital waiting for a nursing home bed. They are not acutely ill. They do not need aggressive medical treatment. They need a nursing home. But they can’t get one because of the massive shortage of nursing home beds. And while I strongly applaud the government for planning to build more beds, they won’t be here for 4-5 years.

At the nursing home I work at, normally 60 patients could be housed, but it’s now limited to 45 because of the rules implemented during the pandemic. I imagine it’s one of many nursing homes that has been limited. While opening up those closed beds (at all the homes) likely won’t be enough, it will help alleviate the stress on hospitals. This is particularly important given (as I write this) no one knows how bad the on coming Omicron wave will be.

But wait – are we not risking increased covid infections in the nursing homes by doing this? We would be increasing, for lack of a better phrase, population density in these homes. The answer is not as straightforward as one would think.

First we now know that three doses of the Covid19 vaccine provides the maximum amount of protection. Just about every resident of a nursing home has had three doses – as have staff. There will never, ever, ever be a vaccine (for any disease) that is 100% effective. But that fact that our most vulnerable patients have had three doses is incredibly reassuring.

Second, we would have to ensure that nursing homes have the funds to put in proper air purifiers (with Hepa Filters) in their facilities. I’m not asking for a complete re-vamp of the HVAC systems (that will take too long). But even small portable air purifiers will make a difference.

Third, we would need to ensure a rapid swab and immunization policy for staff and visitors of nursing homes to further reduce the risk of Covid entering a facility. Just tossing it out there but how about all staff get swabbed once a week regardless of vaccine status, and visitors twice a week?

Fourth, as one of the smartest people I know put it, a bed is just a piece of furniture. We have to ensure that the homes who are short on staff, now have the ability to hire extra staff to take care of the residents in these beds.

The health care system is a behemoth. It is also interdependent on all of its various parts working together. A shortage of nursing home beds, means more people in hospital waiting for nursing homes, which reduces the hospitals ability to provide acute care which leads to further backlogs and delays in medically necessary treatments.

We cannot make nursing homes 100% safe (we can’t make anything 100% safe). But re-opening currently closed nursing home beds in the safest possible manner, will be a small step in the right direction. It will also provide the hospitals with a little bit of extra capacity, should Omicron stress the system more.

Critical Decisions Looming for Health Care

The past three months have seen us undergo a stress like we’ve never seen before in our lives. People have lost their jobs, been socially isolated, and, importantly, non COVID healthcare has been delayed significantly. It’s estimated that 12,200 hospital procedures are delayed each week in Ontario alone. (Back of napkin math suggests 125,000 procedures have been delayed since the start of the pandemic).

In Ontario, these sacrifices have had the desired effect. The number of patients with serious complications from COVID has been trending down. Because we are not able to test everyone, I look at the number of patients who are in hospital due to COVID, and especially those who are on a ventilator, as an indication of how widespread the disease is. Because Canadians did what was necessary to protect others, our hospitals have not been as overwhelmed as many had feared.

However, we are now facing another critical situation in healthcare. The complications that are arising in the people who had their healthcare delayed are reaching alarming proportions. Even at the best of times, our healthcare system was overburdened and overwhelmed. To add to all of that this additional backlog, and the fact that many of those patients have deteriorated and are sicker, and, well, you understand the dilemma we are facing.

I don’t have a degree in biostatistics, like current Ontario Medical Association (OMA) President Dr. Samantha Hill. I can’t crunch all the numbers and give you a statistically valid analysis of what we are facing. I can only speak to what I’m seeing in my own practice.

  1. a patient with significant stomach pain who had scans delayed for a month, only to discover cancer
  2. a patient who I diagnosed with melanoma, who still hasn’t gotten the required wide excision, and lymph node biopsy 8 weeks later
  3. a patient who sent me an email clearly indicating the desire to commit suicide because of the mental health effects of this pandemic (I got a hold of them and appropriate measures have been taken)
  4. a patient with a cough since January who still hasn’t seen a specialist
  5. a sharp increase in patients requesting counselling or medications for the stress and depression directly caused by the effects of the pandemic
  6. at least 5 patients who were already waiting for joint replacement surgery now delayed even more

Keep in mind that I am just one comprehensive care family in doctor in a province that has almost 10,000, and you get a sense of the scope of how much these delays are going to affect people.

This is why there is a real dilemma for those who make decisions about when and how to open up health care (and everything else). If we loosen restrictions, start opening the economy, and allow scenes such as what happened at Trinity Bellwood’s park, the number of patients with COVID will increase. But if we don’t, other people will die, or at least suffer life altering illnesses, from non-COVID related diseases.

In cold, unfeeling numbers, the worry by people like my esteemed colleague Dr. Irfan Dhalla is that we will accept between 10-40 deaths per day from COVID in Ontario. But the reality is that about 275 people a day die in Ontario from a myriad of causes (cancer, heart disease, stroke, suicide etc). What if the price of lowering the 10-40 numbers to zero, is to increase the 275 to 325? To be clear, I don’t know if we are at that point, and even more frankly, I doubt Ontario’s archaic health data systems could even help us figure it out. I just know that has to be a critical concern going forward.

So what can be done? The OMA has released a document on emerging from the lockdown, referred to as “The Five Pillars” paper. This is an excellent paper and it is worth reading. I would, however, add the following thoughts.

First, it’s obvious now, that wearing face masks going forward is essential. A look at Japan shows they did everything wrong, except wear masks, and they have one of the lowest COVID rates around. (And yes, I and others told people not wear masks before and in hindsight that information was wrong). This is particularly important to mitigate the expected second wave of COVID in the fall.

Second, we need to move procedures out of the hospitals where possible. Many procedures like colonoscopies, cataract surgeries, diagnostic imaging, minor surgeries and so on, can be done outside of hospitals. Ontario has an Independent Health Facilities Act which licences these premises and ensures that they follow a high level of standards. They tend to operate more efficiently than hospitals and can see more patients than hospitals (whole bunch of reasons why). Previous Ontario Health Minister, “Unilateral” Eric Hoskins stopped licensing them, and it’s a decision that desperately needs to be reversed.

Third, we need to get our health data collection done properly. In Ontario, the plan was to develop Ontario Health Teams (OHTs) throughout the province that would allow the different agencies that cared for a patient (hospital, home care, physicians etc) to co-ordinate care. As Drs. Tepper and Kaplan point out, “fighting this pandemic requires collaboration from every part of the system and the patient voice. That is the promise of OHT.” To do this properly requires seamless electronic integration of a patient’s health record, and this should also serve as the basis for collecting COVID data. A system like this could also aid with contact tracing if done properly.

For the sake of the health care of all Ontarians, we need to open up health care and the economy, and we need to do that sooner rather than later. With a little bit of vision and forward thinking, it’s possible to do this in a safe manner. Let’s hope that’s what we see in the next few weeks.

The Cruelty of COVID-19

We’ve been living with restrictions caused by the COVID-19 pandemic for over two months now. I recently lost a patient due to COVID-19, and this loss caused me to reflect on the effects of the disease, and it’s impact on society. There really is only one word to describe it.

Cruel.

This disease is unrelentingly, unwaveringly and inexorably cruel.

This has nothing to do with the actual pathology (the conditions and processes) of the disease. That in itself, is in line with a bad viral illness. You (mostly likely) get a fever,cough muscle aches, etc. In people who are predisposed (elderly, those with immune compromise) COVID-19 is more likely to get into the lungs and cause inflammation. There is, of course a much higher rate of death for those who have multiple other medical conditions.

Doctors have seen viral illnesses throughout the years, and this pattern of the weakest among us been more adversely affected is one that we are all aware of. Indeed, my patient was elderly and had a number of medical problems. Truth be told, it would not have been unexpected for my patient to have died anyway from any of the other conditions they had. While tragic and sad, the fact that COVID-19 took them when infected, is no real surprise.

Instead, however, the cruelty of this disease is manifested in how my patient, and the grieving family spent the last days. My patient was in hospital, isolated, and alone. No family could visit. No comfort in their last days and no ability for the family to say goodbye, which I know will haunt them for a long time to come.

But it is not just the patients with COVID-19 who are dealt this cruel fate at the end of their lives. Another patient recently died in hospital due heart disease and was COVID-19 negative. Didn’t matter, the new restrictions in place to increase physical distancing and reduce spread (all of which make sense on a population level), meant that they too, died alone, with no contact from family, and the grief of not saying goodbye will haunt their loved ones as well.

This doesn’t apply just to hospitals either. The local hospice (my community is fortunate to have one of these) has new, stringent guidelines in place for their palliative patients. Only one visitor per patient at a time. A maximum of two people allowed to visit at all (what happens if you have more than two children who want to say goodbye). Common area not to be used, so no sharing your grief with other families (which is often therapeutic).

Yes, I know, communication via online tools and phone is encouraged. But we humans are social creatures. We need to see each other in person. We need to hold hands. We need to hug each other. We need physical contact. Yet we can’t have it. Of course, this is necessary and appropriate. But that doesn’t make them any less cruel.

The further medical victims of COVID-19 are of course, the patients whose care has been delayed while waiting for the acute stage of the pandemic to pass. My patient who has a growth on her ovary, and has not been able to get a repeat scan (and worries daily about what it could be). My patient with chronic hip pain who was already waiting for 12 months for their hip replacement surgery before it got cancelled since it was “elective”. Numerous patients with cancer who have had their treatments delayed. The 35 (minimum) whom the Health Minister herself said may have died due to the care that was delayed by this pandemic.

Then of course, there are economic victims. The 44% (!!) of Canadians who lost work due to the pandemic. They now struggle with finding ways to pay the bills and provide shelter and food for themselves and their families. The toll as they struggle is heartbreaking.

We are also seeing an increase in domestic abuse, more people with alcohol and drug problems relapsing, and warnings of Post Traumatic Stress Disorder in physicians and allied health care workers who treat patients with COVID-19.

All of the above are victims of the cruelty perpetuated by COVID-19.

But in all that, there is, to my mind, hope.

There has also been this year an explosion of gentleness, kindness and decency amongst Canadians. Whether it is a grass roots group like ConquerCovid19 (which has, to my mind saved an untold number of lives and reduced morbidity), or simple acts of gratitude like shining a light for doctors, these acts make a difference. Whether you provide PPEs, or grocery runs, or other support to health workers, you are making a difference. Whether you call your friend to check on them after they have lost their loved one, or check on isolated seniors, you will make a difference. Whether you sing songs like these students or these doctors, you will make a difference (seriously, click the links, those songs are great).

Or if you are the unknown (to me) person who left this on the front lawn of my office building…

… you made a difference.

“Gentleness is the antidote for cruelty.”Phaedrus

Indeed, while it seems that COVID19 is inexorably cruel, the gentleness and kindness that has been exhibited by so many people proves that we will get through it, and we will succeed. It will not be easy. And we will need more kindness and gentleness than we thought possible, but we can do it.

Human kindness has never weakened the stamina nor softened the fibre of a free people. A nation does not have to be cruel to be tough.” Franklin D. Roosevelt.

Canadians have shown COVID19 what we are made of this year. We have shown it that its cruelty is no match for our kindness. We have shown it that we will beat it and all it’s complications, though it will take time and continued effort.

So continue to be good to one another. And together, we will win.

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.