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.

Does Ontario’s Digital Health Strategy Meet Our Needs?

That the health care system is currently in a state of crisis is no secret. That we need to look at bold, radical transformation of the health care system is no secret. That fixing health care means fixing family medicine first is well known. But in order to do all of this, we must finally fix the mess that is digital health infrastructure in Ontario (indeed, all of Canada).

If you speak to any health care worker about Digital Health/Electronic Medical Records(EMR)/Health Information Systems(HIS) you are most likely to elicit a loud, pain filled groan. EMRs have long been cited as a leading cause for physician burnout. Incredibly, 7 out of 10 physicians (!!) have some form of EMR induced stress.

Even the Surgeon General of the U.S. stated that EMRs needed to be fixed (Dr. Glaumcoflecken’s “there are so many clicks” is the exact response you’d get from me):

The reality however, is that there is a bad way of implementing a digital health infrastructure and a good way.

A bad way would be what the four hospitals in my neck of the woods did last year. Implement Meditech Expanse with it’s cumbersome modules, painful clicks, restrictive algorithms and emesis inducing user interface. Better yet, force doctors to learn this odiously inhumane system in the middle of a pandemic when they were already burnt out. The obvious result? At Collingwood Hospital (where I still have privileges but may not after this blog), many family doctors are leaving citing this as a main cause. (Piss off people who are already burnt out, and they leave, who knew?)

A better way of doing things would be to set things up the way my colleague Dr. James Lane did in (ironically enough) the Georgian Triangle region of which Collingwood is a large part. Set up a system where the whole community is on one EMR. Then allow limited information sharing with allied health care providers. Start with pharmacists, then add in home care providers. As a result, there is secure information sharing between health care providers allowing the optimization of patient care.

Some recent examples from my practice:

  1. I renew a prescription for amiodarone. The pharmacists messages me back on the patient’s chart (no faxing, no finding the chart etc) letting me know that the cardiologist had actually reduced the dose of the amiodarone, and I immediately correct the prescription.
  2. The wife of a patient with dementia is concerned her husband is deteriorating. I send a message via my EMR to the Home Care case manager assigned to my practice. I get a response by end of day saying she’s contacted the wife and will arrange for an in home assessment. (This doesn’t solve the problem of actually finding staff to do the work of course, but at least I know that the referral hasn’t been lost).
  3. I send a CT requisition to radiology for staging of a newly diagnosed cancer patient. The local radiologist has questions so he accesses the chart to look at some of the pathology reports to inform his report of the CT.

There’s many more examples but you get the point. These kind of things can not only enhance patient care, but reduce the admin burden of co-ordinating between different agencies. (I cringe when my friends in other centres talk about how hard it is to get home care to acknowledge that they received a referral much less to do something about it).

But this can only happen if the Digital Health team at the Ministry of Health has the vision, the boldness and the fortitude to force these changes and frankly, I’m not sure they do. I had meetings with some of the Digital Health team when I was OMA President. They are well meaning people who want to improve things. But the strategy they are choosing is doomed to failure.

I probably shouldn’t mention this as it was a closed meeting, but I don’t care any more, and besides, what can they do to me? Stop me from running for OMA President again? One of the senior members of the Ministry’s team explained their strategy to me like this:

“If I want to buy a pair of shoes, I have three apps on my phone that allows me to compare different prices from different vendors, and then I choose the best price. Patients should do that when they access health care.”

Now this fellow was in his 40s, and a university graduate. Clearly he can access multiple apps. Good for him.

But the highest users of any health care system are the seniors and the reality is that they are not as technologically able as our friendly government bureaucrat. Do we really expect an 80 year old with multiple medical problems to flip through three apps if they need health care? What if the apps only access part of the system? You’d need one app to access their family doctor, another to access the hospital and a third to access home care. Would anyone want to do this?

All this will do is increase the plethora of software out there, cause more confusion and a deteriorate the communications between health care providers and add to the work load of physicians (because, you know, we are not already doing enough clerical work).

What about OntarioMD? Aren’t they supposed to advocate for change that will help physicians? I had issues with OntarioMD when I was on the OMA Board. (Long story for another day).

But I do note with interest that OMA Board Chair Dr. Cathy Faulds announced in her Board Report that there is a new mandate for OntarioMD that includes end to end proof of concepts on policy. I personally won’t hold my breath (one bitten, twice shy) but I do acknowledge it’s a step in the right direction. Maybe they can finally get on with some of the work that I advocated for during my term and relieve some of the burden that physicians deal with.

It’s the 21st Century. We still can’t fix the health system without fixing family medicine. But we can’t fix family medicine without fixing digital health. Here’s hoping the powers that be finally realize that.

CMA Should Do What’s Necessary – Advocate for Pensions for Physicians

Both of my loyal readers will know that I have not always been a fan of the Canadian Medial Association (CMA). I was one of the vocal critics of the infamous Vision2020 plan that the CMA developed. Vision 2020 suggested that the main role of the CMA should be to empower patients (and here I thought they were supposed to be a physicians advocacy organization). I also wasn’t really impressed by the sale of MD Management to Scotia Bank either.

Interestingly enough I note that the original links in my blog to the articles on Vision 2020 and the MD Management sale have been deleted from various CMA websites. Such scrubbing suggests the CMA would rather we all forgot about these things too.

It would seem that I am not the only physician who was upset with the CMA. Buried deep in the CBC article on the election of Dr. Alika Lafontaine to the role of CMA President is this line:

“As CMA president, he’ll oversee more than 68,000 member physicians and trainees.”

When Dr. Gigi Osler took over as president in 2018, this Globe and Mail article stated the CMA had 85,000 members. A drop of 17,000 members in four years shows that rather a lot of physicians felt that the CMA betrayed them, not just a loud mouthed old country doctor.

In fairness, since 2018, the CMA has done some things very well for physicians. First, the CMA has had some truly excellent Presidents in Dr. Gigi Osler and most recently Dr. Katharine Smart. While I completely understand the significance of Dr. Alika Lafontaine taking over as President, I was saddened about losing a voice as effective for physicians as Dr. Smart. However, I will say that Dr. Lafontaine knocked it out of the park during his inauguration speech and if he keeps that up it will good news for physicians across Canada.

Drs. Gigi Osler, Katharine Smart and Alika Lafontaine

Secondly, the CMA seems to be making its main priority these days the issue of physician burnout. A brief look at their twitter feed shows them reaching out to multiple media outlets to raise awareness of the alarmingly high burnout rates in the profession.

This is good work and shows an organization that maybe has realized that indeed, there is nothing wrong with advocating for physicians. You cannot have a high functioning health care system without happy, healthy and engaged physicians.

As part of the approach to alleviating the stress on physicians and the broader health care system, the CMA also is advocating for a national licence for physicians. The CMA feels this is a priority and a glance at an advanced search of their twitter feed suggests that they feel this will improve virtual care, increase the ability of physicians to support remote communities and reduce burnout.

Now to be clear, I support a national licence for physicians. But the reality is that this is going to be nigh on impossible to do in the short term. I suspect that this will require an amendment to the Canadian Constitution as Health Care is provincial responsibility. Amending the constitution is a dizzyingly complex process. I suspect that Premiers of what may be considered “have-not” provinces would balk at this, fearing that national licensure would lead to more physicians leaving their provinces for greener pastures.

Instead, I would ask that the CMA employ the philosophy espoused by St. Frances of Assisi:

“Start by doing what’s necessary; then do what’s possible; and suddenly, you are doing the impossible.”

The CMA should advocate for immediate Tax Code changes to allow physicians to have pension plans. This is both necessary and long overdue.

I do feel compelled to point out that it is possible for physicians to set up either retirement plans or individual pensions through corporations. However these programs are extremely variable, not easy to implement, and carry high administrative burdens. They also add to physicians workload to set up, at a time when physicians are so tired from a days work that they don’t really have time to think about such things. I don’t know about you, but when I get home, I want to turn my brain off for a couple of hours (before I log back on to my EMR to review lab work and finish charting). I don’t have the mental bandwidth to think about corporate pension schemes.

Making a few changes to the Tax Code is easy. It can be done at the federal level without involving the Provincial Premiers. Doing it will send an immediate message to physicians by the Federal government that they are doing something right here, right now to make life easier for physicians and reward them for all the extra hours they have worked during the pandemic. It will significantly improve physician morale. As physicians realize that there will be an element of security in retirement planning, it will also reduce the stress level of physicians.

Even better, some provinces have already started retirement planning programs. Ontario for example, has the truly excellent OMA Insurance Advantages Program. (NB – if you are an Ontario physician, you really need to strongly consider enrolling in this program. It’s simple, straightforward and really can take a lot of the usual retirement worry away). If tax code changes came into effect, I’m sure a few lawyers and accountants could convert these programs into true pension plans.

The CMA is a national advocacy organization for physicians. They have made much progress since 2017 in supporting physicians. The next, easiest step for them to make would be to push for physicians pensions. It’s relatively easy to do. If successful, maybe they can turn around the trend of declining membership in their organization.

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.

What Role Should Nurse Practitioners Play in Health Care?

A recent look at some of the news stories around health care do not paint a pretty picture for Family Medicine. In Ottawa, a truly wonderful 41 year old Family Physician (whom I had the pleasure of meeting when I was OMA President) is closing her family practice due to burn out. The BC government is on the defensive over the shortage of Family Physicians. Medical School graduates are avoiding Family Medicine. The list goes depressingly on, but the point is clear.

Family Medicine is in crisis.

Jumping into this environment is former Ontario Deputy Health Minister Bob Bell and his colleagues. To fix Family Practice, they recommend expanded use of Nurse Practitioners (NPs), allowing them to work independently to replace much of what family doctors do. They claim that NPs can independently provide care for rosters of 800 patients, and collaborate with Family Doctors only for more complex patients. The authors reference a British Medical Journal (BMJ) study that suggests this will be “cost-saving.”

Bell doubles down on his beliefs that NPs can replace family doctors on Twitter by cherry picking data, in this case a Cochrane review:

One wonders if Bell and his colleagues bothered to read the reviews. If they had, they would have seen that the BMJ study on “cost-effectiveness” admitted:

“…it was not possible to draw conclusions about the cost-effectiveness of the complementary provider specialized ambulatory care role of nurse practitioners because of the generally low quality of evidence.

And that the “authoritative” (Bell’s words not mine) Cochrane review also stated:

We are uncertain of the effects of nurse‐led care on the costs of care because the certainty of this evidence was assessed as very low.

For those of you not versed in medical literature those phrases are the author’s way of saying they did studies where the results couldn’t be relied upon to be reproducible. Using these to promote a belief that allowing NPs to work independently to replace family docs is…….puzzling.

Bell’s belief that Family Docs are easily replaceable is nothing new. He planned on actually ending his career as a general practitioner. Apparently he thought he could easily slide back into it after having done it for a couple of years early in his career, then gone on be an orthopaedic surgeon for another few decades before getting involved in health administration and the MOH:

I don’t personally attribute any malice to his statement (though others on that thread did), I’m not sure that that Bell realized just how much he insulted every single GP in Canada with his seeming belief that he could simply suddenly switch gears after 4 decades of not being in primary care, and go back to being a GP without at least a residency. Hate to tell you this Dr. Bell, but Family Medicine has changed a LOT since you last practiced it. We have more than just beef or pork insulin for diabetes for example.

More to the point however, is there data out there that actually looks at the kind of system that Bell and his colleagues would propose? One where NPs scope of practice is drastically increased allowing them to work independently, and they replace the bulk of work that Family Doctors do? Turns out, there is.

In South Mississippi, the Hattiesburg Medical Clinic, an Accountable Care Organization that is very similar in structure to the proposed Ontario Health Teams (OHTs), did exactly what is Bell and his colleagues are proposing. Fifteen years ago, based on ongoing shortages in Family Physicians, NPs and Physician Assistants (collectively referred to as Advanced Practice Providers or APPs) were hired and allowed to work separately and independently with physician colleagues.

Did this work? In a word: Nope.

A comprehensive analysis of their findings (minimum of 11 years of data over a large patient population) was published in the Journal of the Mississippi State Medical Association. You can read the details for yourself but here are some highlights:

  • the cost for looking after patients who did not have end stage renal disease (i.e. were on dialysis) or were not in nursing homes was $43 a month higher per patient for those who were looked after by APPs than family docs
  • when the data was adjusted for complex patients, the cost of having an APP look after them, rather than a family doc was $119 per month higher (!)
  • these costs were attributed to ordering more tests/more referrals to specialists and MORE emergency department use (yes MORE)
  • Physicians performed better on 9 out of 10 quality metrics in the review

In short, doing what Bell and his colleagues are suggesting led to poorer overall health care outcomes at an increased cost.

Now to be completely clear, I personally have worked with NPs in a number of ways. I strongly believe they are an essential part of the health care team and provide a valuable service. In my practice, they have assisted me in providing care to my patients. When I had a couple of “cardiac kids” in my practice, I dealt exclusively with the NPs on the cardiology team at the Hospital for Sick Children (never once spoke to a Cardiologist or Cardiovascular Surgeon). When the Royal Victoria Hospital in Barrie had NPs on their oncology service, I discussed issues around cases with them exclusively. The NPs were at all times incredibly helpful to me and my patients. NPs definitely have a role to play.

I would also point out that the Hattiesburg Medical Clinic feels the same way. They strongly valued their NPs, and still have them on staff. But they have modified the way they provide care to ensure that all patients now have a Family Doctor but the visits to the clinic now alternate between the Doctor and the APP. On days when only an APP is in house, telemedicine back up by physicians is provided.

We need to build a better Family Practice system. In order to do so, NPs can and should play an essential role. That role however, is not taking on independent rosters of patients. It is working as valued members of a team that looks after a patient population, where each patient has a Family Doctor.

Covid is Not Over – and It Won’t EVER Be

As provinces across Canada begin to lift restrictions from the Covid pandemic, there is a plethora of opinions raging about this. Some physicians feel the restrictions are being lifted too slowly. Others feel that it is just right. In Ontario at least, the most outspoken group are the physicians who demand ongoing restrictions. They have taken to using #Covidisnotover on Twitter.

Obviously, when dealing with a once in a century pandemic that has truly decimated patients and health care workers alike, there are still going to be unknowns going forward. But personally speaking, I think we have to realize a couple of things. First, Covid is not over. Second, and most importantly, it never will be.

Is the flu over? Is HIV over? Heck, are measles and RSV over? The answer to all of those is no. The viruses are still around, they are still infecting people and are mutating all the time (that’s why we need an annual flu shot).

There are always a certain amount of these viruses in the ecosystem. Why would Covid be any different? We are not going to completely eradicate Covid.

Given this – the question becomes, what do we do as a society?

One option, and certainly one that is promoted by the #covidisnotover types, is to continue ongoing restrictions, for much longer. Be it mask mandates, enforced vaccine passports, or continued limits on indoor capacity, the message from them seems to be to keep imposing restrictions for……well, I couldn’t really find consensus on an end date.

The most common argument for continuing restrictions (in Ontario anyway) is the continued positive case load. There are more positive cases than ever before, so why should we stop restrictions now?

Well, the short version is that while it is absolutely true that our case load is higher now than in, say October of 2020, many other factors have changed. In October of 2020, there were no vaccines. There were no oral medications that could help treat those who were infected. Guidance on the fact that Covid is airborne was still (shockingly) lacking.

In comparison, in March of 2022 over 90% of the adult population of Ontario has two covid vaccines, and are well on the way to their third. Evidence is clear that the vaccines are remarkably effective at preventing serious complications of Covid. There is now a strong emphasis on good ventilation as a way to reduce the Covid burden. The government is providing funding for Hepa filters in schools and child care settings. A protocol for rolling out the new oral medications exists, and, like all things, supply of the medications will increase with time.

So to compare just case numbers from October 2020 to March 2022, quite frankly is just comparing apples to oranges. We need to take all these other factors into account.

The other common argument is essentially “Look at Denmark!“. Pro restriction types point to the fact that Denmark lifted all Covid restrictions on February 1st, 2022, and now seems to have an exploding number of cases and mortality. Graphs like the one below are designed to shock people into thinking there is a catastrophe in Denmark:

But the graph doesn’t tell the whole story, and in fact a much more nuanced approach requiring a deep dive into the data is needed. I was going to try but I can’t do a better job of it than Michael Petersen did in his twitter thread:

The short version is that because so many people have Covid now, we need to do a better job of determining who died because of a covid infection (usually a covid pneumonia) vs who died of other causes, but incidentally happened to have Covid at the same time. A better graph showing the Denmark situation (taken from Petersen’s thread) taking this into account is here:

Before people start jumping all over this, let me also point out that I am acutely aware that there is a significant spike in deaths in Denmark recently, even if not specifically caused by Covid. We clearly need to do a deeper dive into why there were excess deaths. But part of that deeper dive must include whether deaths were caused by the restrictions themselves (delayed care, depression and mental health issues leading to people just giving up etc). In essence, is the cure (restrictions) causing more harm than the disease (Covid)?

Look, lockdowns and restrictions were initially necessary. There is good evidence that they helped to blunt the course of Covid. But there is also evidence that they have harmed society as well. The economic impacts with record government deficits that will tax our great grand children are well known. However, there are also other health care impacts.

In Ontario, we have a back log of 20 million health care services, leaving many patients feeling forgotten. There are consequences to delayed care and I have seen that in my own practice, and expect to see much more in the coming year. Yes, those consequences sadly will include deaths.

All of this is before we even consider the collateral damage done to mental health especially in our pediatric population. As Dr. Jetelina points out in her excellent sub stack, there has been a world wide increase in paediatric mental health issues. A 24-31% rise in children presenting with mental health issues and a shocking 69-133% (depending on age group) increase in children presenting with suicidal thoughts to Emergency Departments.

What does all this mean?

My personal feeling is that while we cannot ignore Covid (it’s a bad disease) and we need to continue to encourage vaccinations (they work), we need to start looking at the health care system as a whole. Should we mask in high risk areas? Sure. But should we continue to isolate people socially and restrict interactions in a lower risk population, when that clearly causes other harms? I would argue no.

We have been making decisions for a long time based on Covid numbers alone. There are other illnesses and disease that are out there, many of which have been worsened by the restrictions Covid has forced on us. We need to start basing our health care decisions on what’s best for overall population health, not just Covid.

Governments Should Listen to the Experts and Ease Covid Restrictions

It’s time.

For the past two years, the majority of Canadians have done their part to help combat the greatest health care crisis in a generation. We’ve dutifully worn masks, social distanced, gotten vaccinated and done our part to help protect others.

When the pandemic began (has it been two years already?), very little was known about Covid19 and still less was known about how to treat it. Public Health leaders did their best to provide guidance in an ever changing environment. They got some stuff wrong (remember how we were all initially told not to wear masks ?). But they got more stuff right (the lockdowns did help slow the spread of Covid19).

We all paid a terrible price to fight Covid. Job losses. Economic uncertainty. Decreased social interaction. Mental health impacts on ourselves and most troublingly our children. Delayed medical procedures. The list could go on forever.

Through it all however, was the hope that at some point the pandemic would either end, or change to a more manageable form and we could start to live more normal, if not completely normal lives. I submit that time has come.

In Ontario, we have almost 90% of residents over age 12 who have had two covid vaccines. This would be the number we were told was necessary to achieve herd immunity. I understand that most people need three shots. But the reality is that with Covid being a seasonal virus that seems to mutate regularly, we may need annual booster shots. Surely we won’t keep restrictions forever because we will likely need vaccines forever.

Additionally, we now have new promising medications to treat covid infections. An oral medication that is 90% effective in reducing hospitalizations has been approved by Health Canada, and early distribution to those at highest risk has already begun. I appreciate we need to ramp up production of the medication, and have more of it in stock, but at least we have viable treatment options.

It’s not just this old country doctor saying we need to ease restrictions more. Last week, Ontario’s Chief Medical officer of health himself stated that we needed to re-assess the proof of vaccination process. Canada’s Chief Public Health Officer, Dr. Theresa Tam admitted that we needed to get back to some normalcy. Despite the fact that British Columbia had some of the highest Covid related death tolls with the Omicron wave, even their provincial Health Officer, the excellent Dr. Bonnie Henry, signalled that restrictions would be easing.

I would note that throughout the pandemic, there have been calls for all of us to “listen to the experts” and follow their guidance. Well, they are all signalling that it’s time to change the approach and that it’s time to start lifting restrictions.

To be clear, the restrictions should not be lifted all at once. There should be a stepwise approach to lifting them, but that stepwise approach should be relatively rapid now.

The first thing to go should be the Vaccine Passports/Mandates. Before I go further let me be abundantly clear – I strongly urge everyone to get vaccinated (unless you are one of the one in 100,000 people who has a legitimate medical reason not to). The covid vaccines were incredibly effective against the alpha to delta variants of Covid. They are “just” really good against Omicron. However, with even Dr. Moore admitting that the vaccines will not stop transmission of the Omicron variant (but will drastically reduce your risk of getting critically ill from it) the passports/mandates make no sense anymore.

As an aside, my loyal readers (both of them) will remember that I wrote on July 30, 2021 that vaccine mandates were a bad idea and would “embolden hesitancy and create more fear and mistrust.” Look what’s happened. We now have our nation’s capital essentially under siege from a convoy of people who have been further emboldened by these coercive measures. Think there is enough trust there to come to an amicable solution? Particularly in light of Dr. Moore’s comments that transmissibility will not change if vaccinated?

This is in no way meant to support whatever the Ottawa convoy/protest/blockade is calling itself right now. They have frankly lost the moral high ground by not calling out the fringe few among them who are anti-semites, racists and just plain loons. They need to leave Ottawa and go home.

None of that, however, changes the fact that since you can get Omicron from a vaccinated person as well as from an unvaccinated person – there is no point to a vaccine passport. Get rid of it now.

Once that’s done, the next step should be to ensure our health care system goes back to full regular work and then some. We are already severely backlogged, and there is a whole lot of overtime needed to catch up on the delayed medical procedures.

Next (and in short order) capacity needs to be increased at restaurants/arenas/other indoor gatherings. We need to allow many of the businesses who have suffered terribly to start getting back on their feet.

The last step should be to remove mask mandates. Covid is airborne, and as such, masks provide a significant amount of protection. It will likely be a bit longer yet before we can say that Covid 19 is endemic (always circulating in the community at a stable level without fluctuating) as opposed to pandemic (essentially prevalent at a higher level with significant impacts on the health care system). So mask rules should be the last to go.

But make no mistake, the harms of all the other restrictive measures, whether on significantly delayed health care procedures, or enormous effects on government budgets and the economy now clearly outweigh the effects of continued restrictions.

It’s time to start lifting.

For those of you interested in such things I briefly spoke about Covid19 on CTV News and the link is below where I did mention vaccine passports had to go.

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.

Corporatization of Medicine Continues Unabated

Last week, a story came across my feed that seems to have been almost completely ignored by most who are in/or follow medicine and health systems. WELL Health technologies announced that it has purchased 100% of CognisantMD, the developers of the Ocean platform. For those who don’t know, Ocean is a platform that links to various EMRs and allows for securely emailing patients, eReferrals, filling out forms online, and a bunch of other features.

Full disclosure, my practice uses Ocean as well (for now). Personally I find it somewhat clunky and not as smooth as advertised, but there are some positive features to it.

What’s the problem then? It’s a friendly corporate takeover. Happens all the time in the business world.

To understand the concerns, let’s look at what WELL Health does. According to their own website, WELL Health offers a wide array of digital health care solutions. But they also state they are “Canada’s largest outpatient medical clinic owner-operator and leading multi-disciplinary telehealth service provider”. In essence, they run the clinics, and physicians work for them.

A further dive into their strategy, under the “Reinvest” tab states:

“Acquisition of cash generating companies leads to increased cash flows which are re-invested to make additional new cash generating acquisitions.”

Pure and simple – WELL Health is a private, for profit corporation. There is of course, nothing wrong with private corporations. Most people who follow my twitter feed know that I am generally pro-business, and on most issues land on the right side of the political spectrum. I firmly believe we need more, not less, businesses in this country and we need to make it easier for businesses to function.

BUT – acquisitions like these, and the continued take over of clinics by corporations should make us ask legitimate questions about protection of individual health care data. It is no secret that the reasons that companies like Google and Facebook have become so successful is that they found a way to monetize personal data. In much the same way, personal health care data has enormous economic value to companies. Whoever can find a way to properly monetize this, will be the next Jeff Bezos/Mark Zuckerberg and so it’s no wonder that companies are extremely interested in getting into this field.

As I mentioned in a previous blog, Shoppers Drug Mart, for example, recently acquired a stake in Maple, a leading virtual care only provider for $75 million. They continue to advertise on their website (as of Dec 6, 2021) the ability to diagnose strep throat virtually (which personally I find questionable) and then to send antibiotics to a pharmacy near you (I’m guessing there is going to be a Shoppers Drug Mart near you).

Screen shot as of Dec 6, 2021

In a circumstance where a patient contacts Maple, the doctor or NP gets paid to virtually assess a patient, Maple gets a percentage of the fee to cover overhead – which presumably will be reflected in shareholder value to Shoppers. If a prescription gets sent to a Shoppers, well, they make a profit there too. Neat business model.

But it’s not just companies that already have an interest in providing health care related services that are trying to get involved in this field. Amazon is jumping into health care with a telemedicine initiative. Google has long planned to get into health care, and while not terribly successful yet, I doubt they will stop trying. Heck even Uber (!) wants to get involved in health care.

It’s easy to see why everyone wants in. There is a lot of money and potential profit in health care. And while I am all for companies making a profit, that doesn’t mean that we can’t ask some hard questions about the protection of personal health care data such as:

  • How secure is the data that is being held in the servers owned by these corporations?
  • How do we ensure personal health data doesn’t go where it’s not authorized? (eg. supposing the parent company owned a family practice clinic AND an disability insurance company)
  • How do we ensure personal health data is not to be used to monetize other aspects of a business (eg. supposing a walk-in clinic was owned by a pharmacy. A patient attends there for a renewal of cholesterol medications, and then gets ads offering, say, flax seed oil capsules that are helpfully sold by that same pharmacy).
  • How do we ensure aggregate health data housed in those servers is only used to help the community at large (eg. finding communities that may need extra resources for, say opiod addiction).
  • If a physician stops working at a clinic owned by MegaCorp Inc. for whatever reason, how does that physician access their charts after the fact (I’m aware of a number of cases where access to patient records were cut off immediately upon the physician leaving such a clinic).

I’ve just posited a few questions. I’m sure there are many more. I believe that most Canadians strongly value health care privacy. As more and more businesses attempt to get involved in health care delivery, it is vital that we have a framework for oversight that ensures that patients have the absolute right to protect their personal health information. Sadly, I don’t see any organization/government agency out there asking these important questions.

Time for the OMA Board to Invoke Arbitration in Stalled Negotiations

While most front line physicians continue to deal with the ongoing Covid-19 pandemic, and the resultant backlog of care, the OMA has continued to perform it’s most important function, that of trying to negotiate a Physician Services Agreement (PSA). A quick summary of what has already been disclosed:

  • The Binding Arbitration Framework (BAF) between the Ontario Government allows for negotiating a Physician Services Agreement (PSA) every four years. The last one was for 2017-2021 . We should already have had an agreement for 2021-2025 but the Covid Pandemic got in the way and delayed negotiations.
  • Negotiations for a PSA are supposed to start the year before expiry of a PSA. There is a framework that allows for a minimum of 60 days for negotiations following which either side can call for mediation. After a minimum of 60 days of mediation, either side (or the mediator) can call for Arbitration.
  • IF Arbitration does occur, the Arbitrator must hand down a ruling within 60 days of the conclusion of the arguments presented at Arbitration. After the ruling is handed down, the work of implementing the Award (or if by some chance an agreement is reached – the PSA) begins, and that in itself can take several months to a year. Those of us who were involved in the last implementation process in any way likely still have nightmares about how complex and fraught with challenges it was – I know I still do.

For the current negotiations, we know the following:

  • Negotiations began in October of 2020. The OMA Board gave the Negotiations Task Force (NTF) a mandate for negotiations. A mandate is essentially a confidential, bare minimum set of asks that the NTF must get from the government before accepting a deal. Considering there is no deal, the NTF clearly has not met that minimum. And no, the members can’t know what that is, it would significantly compromise the negotiations process.
  • Mediation began on April 9, 2021. “A large gap” remained between the OMA’s asks, and the MOH’s offer as of June 2021. As I’m no longer on the OMA Board, I have no idea what the gap is like now. Obviously, if there was no gap, we would have a deal by now.

Why should the OMA Board move to Arbitration now? Why not follow the mediator Mr. Kaplan’s recommendation, and wait till January 25, 2022 to go to Arbitration? Wouldn’t going against his recommendation run the risk of adversely affecting the outcome of a potential award?

Because health care is political in Canada. Being political, the time for governments to attack physicians is always, always, always early in their new mandate. In 1991, the NDP government of Bob Rae imposed a hard cap on the physicians budget (first year in power). In 2015 in the first year of Kathleen Wynne’s government, she also imposed unilteral cuts to physicians and in 2018 the Doug Ford government tried to take away binding arbitration.

The short version of the above is that I’m old, and I’ve been screwed by the government of every political party. It doesn’t matter who wins the provincial election of June 2022, the government that is in power will be sorely tempted to revoke any arbitration award if it seems to meet their short term interests. (Yes I know, the BAF is “evergreen” – meaning the process should continue in perpetuity, but the reality is that governments do stupid things all the time, and if one government has tried to take away a BAF process from physicians to suit their interests, then we can be sure another will as well).

And NO, having Arbitration currently as scheduled for Jan to March 2022 is not good enough. Finishing Arbitration hearings at the end of March gives the Arbitrator until the end of May for a ruling. By that time the election campaign will be in full gear, and Ministry bureaucrats will do absolutely nothing to implement any award as they wait for the outcome of the election.

Obviously, going to Arbitration now entails some risks. The NTF will likely argue that the Arbitrator himself recommended waiting till January, and we should try our best to seem reasonable to him. I have a great deal of respect for the NTF for the job they’ve done for the doctors of Ontario, in particular the negotiation of the BAF. But they are paid a lot of (well deserved) money to let the Arbitrator know of legitimate concerns of the membership.

I’ve met the Arbitrator and I have no doubt he will hand down a fair decision, whether in December or March. But members have every reason based on history to fear politicians of all stripes, and it’s the job of the NTF to let him know that that’s a legitimate concern.

Moving to Arbitration immediately, means the Arbitration hearings end likely by the end of December. An Award is announced (likely) by March. At that point, the government is faced with accepting the award, or revoking it three months before an election, and risking the type of anti-government ads the OMA did so well last time. By the time the election is over, whoever wins, the MOH bureaucrats will be well on the way to implementing the award and any “noise” that the award is too much (there will always be noise) will have gone away.

From the OMA’s Negotiations Page

The OMA’s main responsibility is to negotiate a fair PSA for members. The BAF is the best tool they have for not only keeping the government honest, but for political use to reduce the risk of awards being overturned. (NB- There’s no guarantee of anything, politicians do stupid things all the time. This is simply about risk reduction).

Will the OMA Board stand up for members and direct the NTF to immediately move to Arbitration, as we are now legally allowed to? I guess we’re going to find out.