#healthcare – Page 6 – justanoldcountrydoctor

A Message for Medical Students Who Didn’t Match on CaRMS Day

The following blog was written by Dr. Darren Cargill (pictured inset) and originally appeared in the Medical Post in a modified form and it’s full form on his substack. It’s a great message for medical students who didn’t match on CaRMS day, and is being re-printed here with Dr. Cargill’s permission (and my thanks) so that it is more widely available in an un-gated site.

J.J. McCarthy and the UnMatchable

“Those Who Stay Will Be Champions”

On November 14, 2020, Michigan was blown out by Big Ten rival Wisconsin by a score of 49-11, dropping the Wolverines to 1-3 in a pandemic-shortened season. Questions were swirling about if former Michigan quarterback Jim Harbaugh’s would remain as head coach at his alma mater. The Wolverines would finish a the season a disappointing 2-4.

On November 15, J.J. McCarthy sent out this tweet:

What does this have to do with health care in Canada?

I have previously written about my own failures and setbacks. From dropping out of University in 1994 (and 1995, just to be sure), to going unmatched through CaRMs in 2003.

Match Day 2024 is March 19th. I could have simply reposted my Substack from last year and moved on.

But Michigan’s 2023/24 run to the National Championship was calling me.

Anyone who knows Michigan football understands how it works. They run the ball down your throat. They tell you what they are going to do and then challenge you to stop them. Four yards and a cloud of dust. Big Ten Football.

Former Michigan QB Tom Brady played with a chip on his shoulder his entire career. After winning a national championship at Michigan in 1997, Brady was drafted 199th in the 2000 NFL draft. He was not expected to be the GOAT, experts weren’t even sure he would make the team. Yet 10 Super Bowls later (and 7 rings), he is the undisputed greatest Quarterback of all-time (talk to me about Patrick Mahomes in 20 years).

After Michigan’s loss to TCU in the College Playoff last year, McCarthy stood on the field and watched TCU celebrate.

As detailed by Sports Illustrated: “There’s perhaps no greater insight into an athlete’s psyche than seeing how they act following a crushing loss. Michigan quarterback J.J. McCarthy gave fans a small glimpse into his mindset after the Wolverines’ devastating 51–45 defeat in Saturday’s Fiesta Bowl.

Playing in the College Football Playoff for the second straight year, Michigan (13-1) was unable to overcome a handful of missed opportunities and came up just short in the national semifinal against the Horned Frogs.”

I see a lot of Brady in McCarthy. Quiet confidence. A leader of men. Resolve in defeat.

Today, J.J. is QB1 for the 2024 College Football National Champion 15-0 Michigan Wolverines.

J.J. enters the 2024 NFL draft this spring. A lot of people (usually Buckeyes) question his ability. They call him a “game manager.” They doubt his arm strength.

Going unmatched in 2003 gave me some serious doubts about my abilities. My skills.

Was it a mistake to go into medicine? Could I be happy in another field? Did I leave the stove on?

Today, I am the only physician in North America with Fellowship in the College of Family Physicians before Canada, Royal College of Physicians and Surgeons of Canada and the American Association of Hospice Palliative Medicine.

The NFL draft is much like the CaRMs match. It distills years of hard work and sacrifice into one binary answer: matched/unmatched.

To my fellow UnMatchable: Take 3 deep breaths…and have faith.

“Destiny is calling. Open up your eager eyes.”

#GoBluE

PS I rushed the field at Michigan Stadium for the first time this year when the Wolverines beat THE Ohio State Buckeyes (again). Destiny calls.

I then watched the Championship game with my friend Mark, who recruited me to Windsor. Destiny calls.

About Asking for Reduced Admin Burden From the MOH….

Lots of talk on the net about how the economic model for family physicians no longer works in 2024. My own blog site has had guest posts dedicated to this issue. There has been some criticism of this position. Dr. Darren Larsen in a reply to the post linked above suggests he is “not seeing or hearing…ideas for solutions“. He further states that all paying doctors more will do is create a “better-paid, unhappy professional. Nothing has changed.”

Others have made the similar comments. There is nothing philosophically wrong with the argument to reduce workload instead of raising pay. Practically speaking however, history has repeatedly taught us that the Ministry of Health (MOH) bureaucracy is incapable of delivering on that promise.

Some personal stories:

In the mid 2010s I was a Peer Lead for OntarioMD (no really!). I was frustrated by the Ontario Lab Information System (OLIS) because I had to manually retrieve all the lab work for a patient individually in their chart. Hospital Report Manager (HRM) by comparison, sends reports on all my patients directly to one inbox. (why we need two systems – and now more, is another story). The then VP of OntarioMD informed me they were working on “Practitioner Query” – which would allow me to get all my lab work from OLIS in one inbox. This was supposed to be ready in six months. That was over a decade ago.

From 2014-2018, thanks to the vision of my colleague Dr. James Lane, we developed an integrated health portal as part of our Health Links project for South Georgian Bay. For $35K a year, we were able to ensure that nursing homes could message physicians on their EMR. We dramatically reduced paperwork for physicians from nursing homes, improved health care outcomes, and reduced hospitalizations thus saving the entire health system money.

The MOH bureaucracy couldn’t wrap its head around this and wouldn’t allow it to continue.

For those of you who think I should have told people about this project, I wrote an article in the Toronto Sun about it. Afterwards, I got invited to do a presentation on this with the then CEO of eHealth Ontario and her senior team. Heck, when I was a keynote speaker at OntarioMDs Every Step conference in 2019 (no really!) I presented this project. The then head of the MOH Digital Health Team was there and heard it. Still, the bureaucracy couldn’t see their way towards allowing a project that saved physician time (and improved health care outcomes) could continue.

Ok, ok, so this blog is just for me to complain about not being listened to right? Well no, there are multiple other examples.

One workload issue for family physicians is keeping track of which of our patients get immunized for which vaccines. If only there was a central tracking system that sent the information to us directly. Wait, there is! The Covax system for tracking Covid vaccinations. Obviously the easiest and most sensible thing to do is expand the already existing system to add all the other vaccines so we get notified (eg when public health gives Gardasil). Yet 3 years after Covax, the MOH can’t even make this simple common sense change.

More? When I was on the SGFP Executive, one of our senior physicians told us the story of how he was on a working group to make the schedule of benefits (the fee schedule for Ontarios doctors) easier. After six months of meetings, they made a decision to add a comma to the descriptive sentence of one code. One comma in an 800 page schedule.

I could go on but you get the point. It’s fine for the MOH to say that that they promise to reduce the Admin burden for family docs. But frankly to these aged and cynical ears, it just sounds like them saying “This time we really mean it, honest!” – kinda like when Lucy promised to hold the football down for Charlie Brown for real this time, with predictable results.

Look, we have a five alarm crisis in family medicine in Ontario. Just about every week brings a story of another physician who is struggling with the economics of running a practice, and is considering quitting.

As with all emergencies, we need to have an effective triage system in place. Deal with the most urgent thing first, then go on to other things. We clearly can’t wait until 2034 for the MOH to implement some of the workload reducing schemes they might have (and no matter how much they promise they really mean it – it will take that long). So the first thing that needs to be done is bring financial stability to family practices so that they can continue to function while we sort out everything else.

Now, given Ontario physicians are in the midst of negotiating a new contract with the Ontario government, I expect the MOH team to say to our own negotiations team something like – “I know you guys want X% increase, but we can only give you 1/2 of that, but we promise to reduce your admin burden so you are working less hard”. I would do the same if I was them.

But, my expectation, and the expectation I think of the majority of doctors in Ontario, would be that the OMA negotiations team looks at the MOH team, and quotes the best engineer in the history of Starfleet to them.

With apologies to Geordi Laforge, B’elana Torres, Trip Tucker, Jett Reno, Andy Billups, and Hemmer – but Scotty was the BEST ENGINEER in the history of Star Trek!

The first step towards fixing the crisis in family medicine is a new physicians service agreement that stabilizes family practices. Once that’s done, work can begin anew on health systems transformation/workload reduction and so on. To try to do it the other way round, or even hand in hand, is a recipe for further collapse of the health care system.

Mark Dermer: On the Ethics of Telling Residents to Avoid Comprehensive Family Medicine

Recently Maria DiDanieli, a system navigator with the Burlington Family Health Team who holds a Masters in Medical Bioethics, wrote an article criticizing myself, Dr. Silvy Mathew and Dr. Nadia Alam for recommending family medicine residents NOT start a comprehensive care family practices at this time. Dr. Mark Dermer responded so eloquently to that, that I asked his permission to reproduce his response as a guest blogger, and he kindly agreed.

Dr. Mark Dermer, a recently retired family physician whom I’m honoured to have as a guest blogger today.

As a recently retired family physician, I am troubled by the fact that you (Maria DiDanieli) have mistaken the fact that you work adjacent to family doctors as sufficient to understand what they face. Worse, your assessment of Drs. Alam, Gandhi and Mathew is unjust.

But that’s not why I am commenting. Instead, I am coming at this as someone with some experience in medical ethics, both as a long-time member of community and teaching hospital ethics committees, and as a teacher of medical ethics to family medicine residents.

To put it simply: Your ethical analysis of my colleagues publishing the opinion piece in question is both facile and flawed.

I crafted an ABCDEF mnemonic to help residents remember six fundamental principles of medical ethics:

A – the right to Autonomy in decision-making

B – the moral duty of physicians to be adhere to Beneficence when caring for patients

C – the obligation to safeguard patient Confidentiality

D – the patient’s right to receive Disclosure of all information pertaining

E – Equity in dividing finite resources among patient populations

F – First, do no harm (nonmaleficence)

We then apply these principles to a given situation, understanding that the principles might conflict with one another. It is very rare that a single principle can be used to judge a given question. We also must accept that there are almost never absolute rights and wrongs, just better and worse answers.

I am confident that we can agree that the current primary care crisis is first and foremost a violation of equity: present circumstances have divided the people who want a family doctor into those who have one and those who don’t. I also expect that you are aware of the evidence that demonstrates that patient outcomes are better when people have an ongoing relationship with a family doctor.

But you make the elementary mistake of applying a single ethical principle, nonmaleficence, to the matter at hand. Furthermore, you seem unaware that physicians graduating from family medicine programs have been entirely consumed with their training over the previous 5-6 years, nor aware that the medical education system has largely withheld what graduating residents will face as they enter practice. In that light, the letter is a long overdue disclosure that brings transparency to the current state of family medicine.

That’s right, physicians have the right to disclosure too. We also have rights as people to autonomy, confidentiality and equity. Yet when it comes to our work, we are forced to accept legislated pay and work conditions from a monopoly payer, the government. And the government uses the fact that physicians are independent contractors to justify the fact that we are not entitled to the same cost-of-living increases paid to other health or educational professionals.

Finally, I think you fail to recognize that in family medicine, we face unusual challenges to persistently align with all the principles of medical ethics, which work best when applied to “cases” (a single patient at a single moment in time). In contrast, family physicians’ work is longitudinal and includes significant responsibility to populations of patients as well as to individuals. That means that we accept short-term harm when we do things like stick vaccination needles in people’s arms or wean them from opioids, understanding that we are looking to provide a net benefit in the medium to long term.

To my mind, that is precisely what Drs. Alam, Gandhi and Mathew have done. In other words, they are acting very ethically. For while the short-term consequences of their disclosure may accelerate the intensification of the immediate crisis, the sooner the crisis provokes action the sooner we start climbing out of this horrendous hole.

Dr. Alex Duong: The Challenges Facing an Early-Mid Career Family Physician

Dr. Alex Duong, a family physician from the Vanier district of Ottawa (which amazingly enough is one of the more underserviced areas of Ontario).

Recently, Maria DiDanieli, the clinical lead for system navigation at the Burlington Family Health Team, published an opinion piece in Healthy Debate that was critical of the decision of Drs. Alam/Mathew and yours truly to recommend that family practice residents bide their time instead of starting up a comprehensive care practice in Ontario. Dr. Duong replies and has kindly allowed me to reproduce his reply here.

I am a full-time community family physician, and I read this article with great disappointment.

I am at the face of our health care system. When patients cannot get a timely breast biopsy or a knee replacement, they come to ask me. I address their frustrations, alleviate their pain, and manage expectations.

I am the backstop when issues are missed during transitions in care and issues that require follow up.

I am the navigator that helps patients, and their families orient themselves to housing resources, mental health and financial resources.

I am the advocate for my patient’s health when they deal with their employer or insurance companies.

I do all these things and more, alongside everything from newborn care to palliative medicine.

I, like the great majority of family physicians, take pride in our work, and in what we contribute to our patients and the community at large. But Banks do not grant loans for a new clinic based on my contributions to Ontario’s healthcare system. My rent payments do not decrease because of the positive impact I make on my patients’ lives. The salaries of our exceptional staff are not funded by the sound of clanging pots and pans.

Today, to outfit a new clinic with the minimum number of physicians for a FHO requires high 6 figures to 1 million dollars, loaned at 6.95% interest. We guarantee our own lease – we are on the hook for ensuring it gets paid for the entire term. We are responsible for hiring and ensuring our staff are paid a living wage. We invest our own time in making sure the clinic runs. For many community family physicians like me, there is no assistance for any of this from any level of government. No money for staff, no incentives for starting up, no support for logistics. We are in a precarious, failing business model with ever growing administrative burdens patching the system equal to a part-time job. We have been trying to expound on this, and frankly have been completely unsuccessful in this.

You realize that “… there does not seem to be much political will to improve this situation at this time.” Yet, you ask family physicians to work harder expecting a different result from the government.

You state that “With these current barriers and shifts, any new practice can feel fragile or vulnerable to imminent obsolescence.” Yet, you expect new graduates to take on a massive financial risk: long term lease, EMR contracts, and double their already tremendous debt in start-up costs.

You lament that “Instead of acting as beacons of wisdom, encouragement and level-headed advice, we see a growing shift toward inciting everyone to walk out!”. Do you apply this standard to the teachers in Quebec who recently concluded a strike? Are they less dedicated to their students? Do you apply this standard to all groups who organize to make their voices heard?

The authors, Drs. Alam, Gandhi and Mathew made it clear that there are many options available to new family doctors. They warn of the current state of specifically locking into comprehensive family medicine, to ensure that new grads do not put themselves in a position where they will be burnt out early in their career. To me, leadership requires honest conversations, not empty promises, or exploiting the ideals of new family doctors. I find it unethical to sell a romantic vision of what it is like to start and maintain a Family Medicine practice in the current environment. It is a recipe for moral injury when those ideals run flat into the economic realities, as I have experienced.

And frankly, to say to those of us, like myself, still practicing longitudinal family medicine we should be working harder, or we are just doing family practice wrong is demoralizing. It is grossly offensive to my early-mid career family medicine colleagues who have burnt out through great moral struggle and guilt. Disillusioned family physicians who leave longitudinal family practice will not return. The greater harm to the public and to patients is not the Star article that speaks truth to the issue, but the issue itself: that family physicians, whose concerns are being gaslit, continue to leave longitudinal practices.

Open Letter to All Family Practice Residents

The following letter was jointly written by the three of us and published in the Toronto Star on February 20, 2024. It is being reproduced below so that we can share the letter on Facebook as we believe it will be of interest to physicians across Canada.

To All Family Medicine Residents,

We are writing to say congratulations! You are nearly at the end of a decade of hard work, perseverance and sacrifice; ready to start your career and “real life”. You have joined a beautiful and unique specialty. You will be the key to the healthcare system. You will find answers when patients arrive with ambiguous symptoms. Others will tag in and out of a patient’s health journey. You will stay and be an essential part of the beginning, middle and end of every patient’s story. You will save lives.

Your skill and knowledge are unparalleled, and there is no substitute for your expertise.

Which is why with heavy hearts, we, the undersigned, recommend that you do not start your own family medicine practice in Ontario. Not right now.

Family medicine is in crisis. Family doctors in Ontario are unable to provide the care they could and should. We face unprecedented levels of administrative burden, unsustainable business expenses, lack of healthcare resources, lack of social and cultural support for our patients and ourselves and finally, a lack of respect. This has led to widespread burnout and exhaustion.

In short, it is becoming frankly unsafe to run a family practice in Ontario, especially for those just starting.

We are family doctors with decades of experience. We are also physician leaders, past-presidents and board directors of the Ontario Medical Association (OMA), academic faculty, and health policy experts. We understand the situation well.

Do not sign that contract. Do not sign a lease, hire staff, buy equipment, contract with an EMR or any of the million things that must be done so that you can start a comprehensive care family practice.

Starting a practice at this time will require you to continue to sacrifice everything else in your life. If you have debt, you may not be able to pay it down, let alone start living the life you and many others have postponed for so long. You will struggle to spend time with your family, buy a home, care for vulnerable loved ones and more. You will continue to work at a non-stop pace, this time with no end in sight.

You will burn out and like many others, leave family medicine for good. This is why millions of Ontarians no longer have a family doctor.

The Ontario Ministry of Health can solve this crisis.

Governments in Manitoba, Saskatchewan and British Columbia have done so. This past year, they made family medicine a priority – and backed their words with targeted funding toward key programs to support both new and established doctors. It comes as no surprise that they have welcomed hundreds of new family doctors into their communities.

If they can do it, so can Ontario.

What can you do in the meantime? Work in hospitals, hospices, operating rooms and long-term care. Work in obstetrics, anesthesia, as a hospitalist, in emergency or palliative care, oncology, sports medicine etc. Be a locum. Bide your time.

You are skilled, smart, and adaptable. Your knowledge is extensive, demonstrating an unmatched depth and breadth of training. Use it.

When people leave comprehensive care family medicine, they almost never come back.

We don’t want that to happen to you. When the government of Ontario recognizes family doctors as the foundation of medical care, negotiates a fair contract and improves health policies to reflect patient needs in 2024… well, when that happens, we will write a different letter and welcome you to the world you were meant to be in.

We hope by then it is not too late.

Sincerely,

Dr. Nadia Alam, comprehensive care family physician and anesthetist, past-president of the OMA

Dr. Sohail Gandhi, comprehensive care family physician and hospitalist, past-president of the OMA

Dr. Silvy Mathew, comprehensive care family physician and long-term care, past-board director of the OMA

Dr. Corli Barnes on the Challenges Facing New Family Physicians

Dr. Corli Barnes , pictured here, guest blogs for me today. She is a Family Practice resident who is just completing her residency. She sent the following letter to the Sudbury media after reading reports about the crisis in family medicine. I thank her for allowing me to reproduce the letter here.

Hi Len,

I read your article about family physicians. I am a second-year family medicine resident here in Sudbury, ON, originally from Manitoba. Thank you for taking the time to help raise awareness about the crisis in Family Medicine. I wanted to write to you to offer a viewpoint not often accounted for in this conversation.

I’m about to graduate as a family physician. After ten years of climbing that Mount Everest, eight of those years without an income, paying for two full-time degrees plus inflation and living costs, I’m $350,000 in debt. That’s living on around $31,000 a year.

The government just denied me loan repayment assistance because I get paid ~$68,500 a year as a resident. The cost to write my final exam just went from around $1,500 to $4,201. When starting a practice, a monthly bill of anywhere from $7,000 to $12,000 in overhead is waiting for most grads who take up a clinic practice, plus ~$2,000 a month in interest on debt if you supported yourself through school.

When I start practice, I can expect the Ministry of Health to take it’s time (at least two months) to approve my funding model. My first paycheck will come in at fee-for-service levels that won’t cover my costs.

About a year and a half ago, after working a 60-hour week, I started to quietly panic when I did the math to project my net income as an attending physician. Clinic-based family medicine is my passion, and I realized that it wasn’t going to work out based on the way most physicians work. I wouldn’t be able to even begin to pay off my debt.

After all that work, sacrificing my twenties, my health, friendships, and enduring the stress of medical training – I wouldn’t be able to cover my living costs as an attending family physician.

Try imagining uprooting your entire life to go on a pilgrimage to a promise land and when you finally get there, it’s a shell of what it once was. A ghost town with worn out buildings and hardly anyone in sight. You’re 10,000 miles from home and way worse off than when you started.

The only promise this journey has fulfilled is providing the education necessary to safely and meaningfully help people who are sick and enable them to seek wellness.

A family doctor is the only professional that is trained adequately to be able to pick out disease from the general population. It is the only medical specialty educated in every body system, who is there to catch those who fall through the cracks, prevent disease, and deliver medicine in a way that suits an individual.

This work will always be challenging and meaningful, requiring dedication to keep up with rapidly increasing medical knowledge and motivation to continue to seek excellence. The challenge is great, and the reward for doing it well – a healthy patient – even greater. This is why I’m passionate about it, and sad to see it fall apart and go unappreciated. It’s hard to watch as its integrity is cheapened by being grouped into an emerging category of primary care providers with far less training and liability, and have its voice drown out by promises of funding that seem to keep ending up in someone else’s pocket.

Because of the way things are, I have had to pivot considerably by coming up with creative ways to practice medicine and supplement in my income in the future.

Many of my peers have elected to do emergency medicine, hospitalist, subspecialize in family medicine or locum while they contemplate their options.

With every news release, I read about funding for health teams, funding for free schooling for nurses, funding for nurse practitioners, funding for “programs to reduce administrative burden” that I have yet to see a benefit of. I open the news everyday, hoping to read something about increased pay for family physicians. Instead, I read about how negotiations are not going well with the government. I read that the planned increase of 2 or 3% has been cut down to 1% or 0%.

Sometimes, it’s hard to not regret going into any number of specialties I could have. I go to work, and I do my best to help the patient in front of me. They ask about where I’m going to practice with hope in their eyes. They leave feeling better, and I try not to think about the fact that for many family physicians, the thanks for that visit is just $12 to take home.

Eventually, fueled by the same determination that got me into medical school, I started to dig deep to find a solution that wouldn’t mean I would have to abandon my dream of opening a clinic-based practice. A solution that wouldn’t mean I have to give up freedom I’ve waited years for, work unsustainable hours or in a toxic environment bred by chronic underfunding.

I scoured Ontario looking for a place that would help fund the start of my career in a meaningful way while having a sustainable business model that supports good medicine. After around a year of this search, I am lucky to have found a place in Madoc, Ontario but I can report that it is a very hard thing to find.

I am sad to be leaving Sudbury, where I currently live and initially hoped to call home when I moved here in 2022. I hope this letter helps to raise awareness about the difficult situation many residents are in and how urgently family physicians need change.

Actually, Ontario Does NOT Have a Shortage of Family Physicians….

You’re probably wondering if I’ve lost my mind. The media is currently littered with stories about how 2.3 million people in Ontario don’t have a family doctor and how that number is expected to double in two years. Family practices are closing down. In Sault Ste Marie – over 10,000 people are about to be orphaned (left without a family doctor). The Ontario Union of Family Physicians just held an event geared towards helping family doctors leave the profession.

How out of touch must I be to make the assertion, as I did on CTV news recently, that we don’t have a shortage of family doctors?

Truth be told, there is an important distinction that has to made, which is key to solving the orphaned patient crisis. There are family doctors, and there are family doctors who are willing to work in a comprehensive care family practice like I do.

According to the Ontario Medical Association (OMA) website, there are over 15,000 members of the Section of General and Family Practice. These doctors have got their medical licence, are qualified to practice in Ontario, and are able to practice family medicine without any further regulatory hurdles (like getting foreign doctors licensed would entail). There are likely many more as some doctors with a family practice billing licence don’t choose a section – but let’s go with 15,000.

What’s really telling is that only about 9,300 are in what’s called a PEM (Practice Enrolment Model – where a formal agreement exists to run a family practice). The number that are in Fee For Service alone (without an agreement) but still run a practice, is likely only a couple of hundred. So at most we have 9,500 comprehensive care family doctors. The other 5,500+ do something else (hospital only work, clinical associate work, walk in, etc).

From the OMA website. PEM + APP is about 9,300. This would be the number of docs with a formal agreement to run a family practice.

There’s a myriad of reasons why comprehensive family practice is so unappealing, but let’s look at the two main ones.

1)Decreasing net incomes over the years. It is of course, unpopular to talk about the money doctors make. The OMA has historically felt that the general public views doctors as “fat cats” and “part of the rich elite.” So they’ve shied away from talking about physicians incomes or trying to positively frame that discussion – with predictable results.

As Boris Kralj (PhD in Economics, Adjunct Asst. Prof at McMaster and former Staff at the OMA) points out, net income for family physicians has fallen drastically over the past 20 years.

My thanks to Dr. Kralj for allowing me to share his graph.

2) Increasing Admin Burden. I think everybody has heard how family doctors now spend up to 19 hours a week doing administrative work, ON TOP of the time they spend seeing patients. This work is unpaid of course (there is no fee code for admin work). On a personal note, in about 2004, my office, which was already electronic, got a vpn (virtual private network). This allowed me to connect to he office from anywhere in the world. Initially, I thought it was great. I would go on vacation, spend 20 minutes a day taking care of messages and when I got back from vacation – I would not have the backlog of messages to deal with.

This past summer, I went on a hiking trip with one of my sons. He pointed out that I was now spending over two hours a day going through labs and messages. Essentially, family doctors don’t have any vacation now. I don’t care what your job is or who you are, a life without any breaks is unsustainable.

Me last summer, by a lake, on vacation, checking my office messages and lab work (dummy chart)

What can be done about this? How does one make family medicine more appealing? This may rub some people the wrong way but the first step is simple. Pay family physicians more. In Ontario, the most common fee billed by a family physician is about $37. (The last time I got a haircut, I paid $40). Out of that $37 the family doctor has to pay their nurse, receptionist, rent, cleaning, supplies and so on. Gets used up pretty quickly.

Additionally, you need to pay physicians for admin work. If there is 19 hours of admin work that needs to be done – it’s only fair that work is paid for. There are people who are skeptical this will work. To them I would point out that British Columbia has gotten 700 more family doctors since increasing the pay to family physicians.

You mean if you increase the income for a job, more people will apply for it? Who knew?

B.C. isn’t even the province that pays physicians the most. That’s arguably, as I have written before, Manitoba. Saskatchewans new deal is also much better than what Ontario offers.

The second aspect is to reduce the admin burden for all physicians. Many experts suggest this is a process that will take time. They are the same experts that oversaw the increase in Admin work for physicians with “oh it’s just one extra click or it’s just a simple form”.

To reduce the Admin burden significantly, one needs to drastically revamp digital health care. Get rid of eHealth Ontario and OntarioMD, and run all decisions through the Digital Health Branch of the Ministry of Health. It’s too late to unify all of our electronic medical records, but you can approve one (and only one) patient app that will allow patients to access and transfer their records to the physician of their choice to reduce duplication and waste. That’s the kind of bold steps that we need to take, not just crowing about the fact that doctors don’t have to sign hearing aid forms any more.

Look we already have 5,500 licensed family physicians in Ontario able to open up a practice. If 40 per cent did so, it would end this crisis immediately without having to resort to years long plans of modifying licensing and training requirements for foreign graduates (who in fairness are generally very good).

Do our leaders have the boldness and vision to do the right thing?

Dr. Soni Reflects on the Delays in Emergency Rooms

Dr. Deepa Soni, and Emergency Room physician for over twenty years, reflects on the case of a young woman with appendicitis, and the delays in getting her care.

NB: Recently, Julia Malott spoke out on X (formerly known as Twitter) about how terrified she was about Canada’s health care crisis. She wrote how her daughter had not eaten in 18 hours as she continued to wait for surgery for appendicitis. She expressed concern about the lack of the beds and wondered if her daughter would get surgery before the appendix ruptured.

My friend Dr. Soni, who has worked in an Emergency Department for over 20 years, had, as usual, a very thoughtful and well spoken X thread of her own. (Dr. Soni was NOT involved in the care of this young woman). I thank her for allowing me to reproduce her thoughts here.

The only way these stories (about long delays in Emergency rooms) will stop being the norm, is when patients start sharing their experience like this mother did. Only voters can make federal and provincial governments change because votes are the only currency that matter. Doctors and nurses have been raising alarm bells for years without success.

Canada has one of the lowest number of hospital beds of all the OECD countries, around 2.3/1000 people. In comparison countries like Japan, Korea and Germany are around 13/1000.

Graph showing how Canada fourth from the bottom (!) in hospital beds per capita.

Why does this matter? Having low hospital bed numbers means that words like “flu surge“, and “winter surge” — which have been used for decades to explain away long wait times and hallway medicine, are actually not “surges.” Rather, they are the expected backlog in a system that lacks adequate beds and resources.

The population of Canada is increasing and aging. We are about to enter a silver tsunami where a large cohort of our population will be over the age of 65 and many over the age of 85. This will place unprecedented pressures on our health care system.

What happens when the hospital bed capacity is outstripped by the numbers of patients needing care? It means that the elderly patient who needs admission to a hospital bed to recover from a heart attack has no bed to go to and spends days “admitted” in the emergency department. Bureaucrats call these “unconventional spaces.” What they really are, are stretchers.

Photo of admitted patients lying in stretchers in a hallway as no beds available (found on X)

When the vast majority of the emergency department beds are being used to take care of hospital patients, that means that patients that are waiting in the emergency department waiting room, will wait for hours for care, much like this story is describing.

Media needs to scratch beyond the surface and hold government to account. Real solutions are going to require thinking beyond the four-year election cycle. What will our system look like in 20 years? How do you plan for that?

It’s going to require recognizing the backbone of our healthcare system is primary care. Family doctors are overwhelmed by administrative burden, trying to run their offices and taking care of large practises in the community without adequate resources.

Build community infrastructure with resources like palliative care so that people can remain in their homes comfortably in their last days; and sufficient homecare services so that patients can receive antibiotics and other intravenous treatments at home to ease the pressure on hospitals. These services are vastly underfunded and do not have enough staff to properly provide care for everyone that needs it in the community.

It’s going to require building more nursing homes, retirement homes, seniors services and dementia care programs, as our elderly population will be the largest it’s ever been in this country.

Incentivize and properly pay hospital nurses so that we can recruit and retain them to be able to run departments and programs properly. Currently, agency nurses make at least two times as much as a hospital nurse, and this has created instability in the workforce. Governments need to show that they value nurses and the important work that they do.

Creative solutions like interprovincial licensing of doctors and nurses and a National Pharmacare program will help. While the idea of recruiting from other countries sounds like an easy quick fix, it will not solve anything if those newly obtained doctors and nurses find themselves overworked and burning out soon after arriving to Canada. The system problems are going to impact them just as they have impacted those who are already working in the system. This type of strain is what contributes to moral distress and burn out.

The backlog in the emergency department is a reflection of multiple failing areas that create an overall system that is strained beyond capacity. With each passing year, Canada’s healthcare system has become more and more stretched, trying to provide more care to more people, with fewer resources. Throwing Band-Aids at it is like trying to mop up the floor under an overflowing sink instead of trying to figure out how to turn off the tap.

Stories like this one are happening every day in Ontario and all of Canada. Most patients and families are too busy dealing with the acute health problem to take the time to write to their MP/MPP or to go to the media. But when people take the time to bring these stories to light, a critical tipping point will eventually occur where they can no longer be ignored by government. Because votes matter.

No one who went into healthcare wants to work in a system that makes patients feel like this story illuminated. But we need more voices bringing their stories out in the open. It will improve the system for the people working in it, and for the people receiving care within it. And that is better for everyone.

What Would I Do if I Got Sick? I Would go to Turkiye.

NB. I am a consultant for Medicte, a medical tourism firm that connects people with the Acibadem Health Group in Turkiye. I appreciate my two loyal fans may read this to be an “advertorial” – but it does represent how I feel.

Yours truly at an Acibadem Hospital in Turkiye with their team and representatives from Medicte

Recently, Leger released the findings of a survey that polled Canadians on their thoughts about the health care system. 70% of Canadians worried about not being able to get high quality health care. Surprisingly, only 37% thought the health care system was poor – did 63% not need medical care recently? But the number that should demoralize all of us is that only 17% feel the system will improve.

Like everyone else of a certain age, I’m coming to the realization that the one fight I won’t win, is the battle against time. More of my friends and colleagues are developing health issues. While I’m blessed to be in good health, like 83% of Canadians, I realize that the current health care system (which doctors call horrific and inhumane ), will not provide the access and care we should expect as standard in this country. I can only see things getting worse in the near future.

It does not help that I live in the health system every day. I’ve watched patients I really care about suffer in ways that I would not have imagined possible. Young people with cancer not getting treatment for three months. People with joint pain waiting a year for surgery. Patients developing complication after complication while on wait lists to access necessary treatments.

Most heartbreakingly, I see the toll that the burnout of working in such a hellishly damnable health care system is taking on doctors, nurses and other allied health care professionals on a daily basis.

That’s why I recently made the decision that if I, or someone in my family needed health care, I would seek care outside of Canada. I am not alone in this. The data is hard to get at, but going back as far as 2014, between 52,000 to 217,000 Canadians were seeking health care outside of Canada annually.

There are a variety of reasons to seek care outside of Canada, and specifically Türkiye:

Getting immediate care. I could get hip surgery next week, not next year. Cancer patients get all the tests they need done within a week, not three months like I’ve seen.
Getting treatments that are not available in Canada. Canada offers a host of great medical treatments, but many are not covered by government plans. Lap Band surgery is one. New, emerging radiation therapies for pancreatic cancer is another. There are more. All of these are available in Türkiye.
Getting better allied health care support. Canada has GREAT nurses and other allied health care workers. But the system does not let them care for patients the best. Last time I was on call at my hospital, I overheard the nurses talking about how they each had 7 patients to look after for the shift. The safe number for an acute care hospital ward is 5 patients per nurse. We have excellent nurses but if you are constantly working at 40% over capacity, things are not going to go well. At the Acibadem hospitals in Türkiye, they have 4 nurses for 15 patients (3.75 patients per nurse).
More cost effective care. I’m fortunate I can afford to pay out of pocket for care if needed. Worst comes to worst I’ll put off retirement for a couple of years to pay for things if necessary. But even I would have trouble with $200,000 (U.S.!) that B. C. resident Allison Ducluzeau spent on her cancer care. Costs in Türkiye for most procedures I looked at are generally less than half of what it costs in the U.S.
First World Standards for Health Care Treatments. All of the Acibadem hospitals are JCI Accredited (the global leader in health care accreditation agencies). This puts them on par (and in some cases better) than top European hospitals.
Türkiye is a well sought after Medical Tourism destination. Medical Travel Market recently highlighted 12 reasons why Türkiye was so well sought after including cost, world class facilities and cutting edge treatments. 1.2 million people went to Türkiye for medical tourism in 2022, mostly from Europe.

As part of my consulting work, I went on a fact finding tour to Türkiye and visited the Acibadem hospitals. To say my jaw dropped would be an understatement.

The team and I reviewing the process for orthopaedic care with their top spine surgeon.

The hospitals (there are 21 in the Acibadem group) look like hotels. Each room is private. The wards are immaculate. All of the staff were incredibly attentive (and yes, spoke English).

I asked to see the MRI, and the staff wanted to know which one (!). Their approximately 170 bed hospital had THREE MRIs, specialized for different conditions. This is on top of the CT scans, gamma knives (cancer treatment), PET scans etc etc. All of the equipment was brand new. I especially liked the MRI that projected a movie onto the equipment, to help children stay calm during the procedure.

This MRI projects a movie onto the surface to help children (and some adults) stay calm during a claustrophobic procedure

I also ran into a couple of top ranked Turkish footballers (soccer players) while there. The Turks are as crazy about football as we are about hockey. Their top athletes go to the Acibadem group.

But what’s more impressive than the top ranked doctors, nurses and equipment is their philosophy of how to provide health care. If you were to sadly, get cancer, you would see all the specialists you need to see (surgeon, medical oncologist, radiation oncologists etc) on the same day. Any tests you need would be organized sequentially and rapidly over the next couple of days (if not the same day). You would have a full treatment plan within a few days.

Contrast this with Canada where you have to have an appointment with one doctor, then wait x number of weeks to see another then x to see another like my patients currently do. All while the cancer continues to grow.

Also, for the record, I did wind up getting care myself at Acibadem. Bad teeth run in my family, and so I went for a dental check up. The dentist examined me, put in two fillings, got the oral surgeon to come by and took out two teeth that were beyond hope, all during the same visit. This would have taken multiple visits in Canada. You could say I put my money where my mouth is. And yes, the care was excellent.

I appreciate this sounds like an advertorial. But the reality is that more and more Canadians are getting frustrated with the long waits for health care and seeking care outside of Canada. It may have started off with people seeking lower cost cosmetic surgery, but now things like orthopaedic surgery, cancer treatments, organ transplants, dental implants and even cutting edge infertility treatments can be had for those willing to travel.

There is never a guarantee of a successful result with medical treatments anywhere (including Canada). If considering leaving the country for care, people should do their due diligence. Make sure you deal with a reputable firm and first rate hospital.

I’ve made my decision, and I know where I’ll go.

If you or anyone else would like to explore options for out of country health care, contact Medicte for a free consultation.

OMA Needs to Communicate Better About Status of Negotiations

Negotiations between the Ontario Medical Association (OMA) and the Ministry of Health (MOH) on a new Physicians Services Agreement (PSA) began this past fall. The first set of bilateral meetings were in mid-October. This years negotiations present a particularly complex challenge as not only is the OMA trying to negotiate a new four year agreement for physicians, but it also has to determine how much of an increase physicians will get this year (more on that later).

Given that we are a few months into the process – I think the OMA as an organization is really not doing a very good job of communicating the status of the Negotiations with its members. The OMA really needs to increase some of the transparency around the negotiations process.

In fairness, there are somethings about negotiations that simply can’t be divulged (and I fully support this and members do need to accept this):

The mandate for negotiations must be confidential, to prevent the other side from knowing what our bare minimum acceptable increase is
The detailed discussions between the Negotiations Task Force (NTF) and the MOH must also be confidential (a lot of stuff that goes back and forth is hypothetical – and to protect the integrity of the process – you can’t disclose this to 40,000 + people)
The briefings presented to the Board and the Section Chairs must stay confidential as well (for the same reasons above).
NB – If we wind up in arbitration, the asks at arbitration are public.

So what should the OMA be informing members about then, given what’s usually a “cone of silence” around negotiations? Well, put simply, there are a number of things that are part of the negotiations process, outlined in public documents readily available to all members. The OMA needs to recognize some members (not just me) will read and wonder about these. (Although I’m probably one of the few loudmouths who’ll publicly write about it).

The Cone of Silence, from the classic series, “Get Smart”

For example, the Binding Arbitration Framework, under which negotiations are now held, is posted on the OMA website for all physicians to see. The framework is pretty clear. After 60 days of negotiations, either side can ask for mediation. They don’t have to, but they can.

We are over 60 days. Perhaps mediation is not needed yet (which would be a good thing). But the OMA can, without compromising the negotiations tell members something like “while we have been negotiating for x number of days, at this time the process continues and we neither side has called for mediation.” It would at least let members who follow this closely know what the stages are.

Similarly, it would be quite reasonable for the OMA to list the dates of the meetings with he MOH and a general list of what they are talking about. Eg Oct 19 met with MOH to discuss Primary Care models, Oct 21 to discuss backlog in radiology etc. (I have no idea when the meetings with the MOH were or what they talked about btw – I’m just pointing out what could be said).

Finally, there appears to be radio silence about the part of the last contract that directly affects this year. This contract was completed and ratified by members and is public knowledge. The parts of concern are:

21. ….the parties will establish a committee that will meet on a quarterly basis…..to review the expenditure calculations. Through this committee, the parties will agree to a best estimate of the year 3 (2023- 2024) PSB expenditures in accordance with paragraph 6 by December 15, 2023.

22. Any agreements reached by the Government with respect to any new physician payment program or addition to an existing program which was not the subject of a proposal by the OMA during the negotiations leading to the agreement for the 2021-2024 PSA will not be included in calculating the total PSB expenditure …..”

It’s obviously past December 15, 2023. Which means we should have an agreement on the PSB expenditures by know. This information is critical to determining how much of an increase we get this year. The OMA had told us that:

“Conservative OMA projections indicate an expected Year 3 increase of 2.8 per cent, with a range of 2.1 per cent to 3.6 per cent”

But if the expenditures are too high, then we potentially get a zero percent increase. My friend Paul Hacker did an EXCELLENT job of explaining this here:

Paul Hacker’s Analysis

As an aside, some of you wondered why I endorsed him for OMA Board Director. It’s because of stuff like the above link. He knows the Board needs to provide proper oversight on the process and ensure it’s explained to members.

Anyway, perhaps this date got pushed back. This wouldn’t surprise me. The MOH Negotiations team was never able to get data on time in the past (there was always an excuse, except for the truth – that they are generally incompetent).

But the OMA should simply tell members this. Remember last year when it was announced to primary care docs that the repurposing of the preventative care bonuses couldn’t be mutually agreed on, and so was delayed for a year? Do the same thing and say the deadline couldn’t be met and you continue to work on it. But don’t just ignore the deadline and hope no one will notice.

Communicating better would also be beneficial for the NTF. There is no task force at the OMA that is more controversial, and gets more….attention…from members than the NTF. Yet what’s missed is that the NTF works really really hard. I remember some of the 18 hour days they put in when I was in various roles at the OMA.

But when communication about the process, and the work they are doing is substandard, members won’t appreciate all that. They’ll simply blame the NTF for what goes wrong (e.g. if we were to get zero percent this year). It would be foolish in the extreme to suggest everyone will love the NTF if they just communicated better. But better communication would at least blunt some of the criticism that will come their way.

Hopefully, the OMA as an organization will recognize this.