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.

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

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

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

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

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

What poppycock.

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

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

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

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

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

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

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

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

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

Shame on all of them.

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

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

HEPA Filters, Focus on Ventilation Can Help Open Economy

This week, much of Ontario moves out of a complete lockdown (I finally get a hair cut!). The move itself has not been without controversy, with some critics saying the government is opening too fast, and others saying they’re opening too slowly.

There is no doubt in my mind that if we can re-open the economy safely, we should. COVID19 has done terrible damage over the past year. Lives lost. Families unable to say goodbye to their loved ones. On going health issues in those who survived COVID19 infections and much, much more. But there is also an increase in the number of people suffering from mental illness, a rise in domestic abuse, and very real economic hardships faced by millions of Canadians.

It has been noted that there were were more deaths than expected in Canada last year, and not all of these “excess deaths” were directly caused by COVID19. We are starting to realize that some of deaths are “indirect”. That’s to say, the social isolation, the lack of emotional, financial and other support, the delayed medical procedures and more, have caused these deaths.

This situation is particularly bad in British Columbia and Alberta, where there were 270 and 360 more deaths than expected between March 15 and April 25 alone, and these were not directly attributed to COVID19.

To be clear, the lockdowns were necessary. And if we open the economy in an un-safe manner, COVID cases will rise again, there will be more death and perhaps even a dreaded third wave. We’ve seen from Sweden what happens when a country doesn’t shut down in the face of COVID. Even their king has admitted Sweden’s approach was a total failure.

It’s just that we cannot ignore the pain and suffering that occurs by a lockdown as well.

That’s why to my mind the focus needs to be on how to re-open safely. We have one of the worst pandemic responses in the world, so we must do better. Is there something we can do, that hasn’t been done in Canada yet?

Turns out, there just might be.

For far too long, Health Canada did not focus on airborne spread of COVID19. They stressed the “droplet” method of transmission, where fluid particles are expelled from your mouth, land on a surface and are then when you touch them, wind up on your fingers, and then into your body when you touch your eyes, nose or mouth. Full disclosure, if you search hard enough, you can find a video of me somewhere on the net saying exactly that, and telling people not to wear masks. It is clearly outdated now, and should be ignored.

Japan, by contrast, focused on airborne spread as far back as February of 2020. Their whole focus was to ensure proper ventilation and using air purifiers with HEPA (High Efficiency Particulate Air) filters in rooms. Everybody was asked to wear a mask early last year. Granted it is culturally more accepted to wear masks in Japan. But the focus was on airborne spread right from the start.

A diagram showing Japan’s process for dealing with COVID19, part of their submission to “Environment International” – September 2020 edition

How well did Japan do? Japan has a population of 125 million people in a country about 3/4 the size of Baffin Island. As I write this, data from their COVID tracking system shows that 417,116 people have been infected (0.33% of the population) and 7,038 have died (.0056% of the population).

These numbers are all the more remarkable considering that Japan did just about everything else wrong. They did not test enough (at least at the beginning), the lockdown measures were half hearted and voluntary, many pachinko parlours (a mix of gambling and alcohol) stayed open, and traffic on their notoriously crowded commuter trains to work was only down 18%.

Health Canada did not even acknowledge airborne spread of COVID19 until November 2020 (9 months after Japan and 4 months after the World Health Organization). Our Covid19 tracker shows terrible results. We have a population of 38 million. Yet as I write this, we have had 826,528 cases (2.17 % of the population or 6.6 x as many as Japan on a pro-rated basis) and 21,309 deaths (.056% of the population or almost exactly 10 x as many deaths as Japan on a pro-rated basis).

It does make one wonder, if we had approached COVID19 as having airborne spread right from the start, could we have saved a number of lives, and limited the lockdowns we endured? And now that the evidence is strong that COVID19 is airborne, should we not have businesses focus on safe ventilation as a condition for opening?

What’s required for optimal ventilation? Well ideally, you should have an HVAC system that exchanges the air in a given room 6 times an hour with an HEPA filter. HEPA filters can remove the vast majority of droplets that the COVID19 virus (and other viruses!) live in. But the reality is that this would be ultra costly and take far too long to replace every HVAC in most commercial buildings. (Should definitely be a requirement for new commercial properties and especially the new nursing homes Ontario is building).


What can other businesses do instead? One of my patients is a manager at a Tim Hortons. They have 14 tables at the Tim’s. What if the restaurant put a portable air purifier with a HEPA filter on each table? There are many brands that cost $80-$100 each for a small size one. But with one on each table (where people would be talking and eating without masks, thus expelling the virus), you could reduce viral spread.

Granted at that price, the air purifiers would only last about six months, but by that time hopefully we will all be vaccinated anyway.

Similarly, we could mandate appropriate air purifiers in other businesses as requirement for opening. To be clear, people should still wear masks, wash hands regularly and physically distance as much as possible. Those are important and necessary precautions for re-opening. But the HEPA filter purifiers would simply provide that extra level of protection. It’s why I asked my nursing home to install them in their facility (and thank you to the owners of Bay Haven for doing that).

Canadians have suffered terribly over the past year. For the sake of our physical and mental health we need to re-open the economy, but do it in away that will not increase COVID19 infections, and not have us yo-yo between lockdowns and re-opening. Focusing on ventilation and HEPA filters can help us do this safely.

COVID19 Has Exposed Flaws In Our Public Health System

“Be hard on the problem, not on the people.” – unnamed OMA Executive

When I was President of the Ontario Medical Association (OMA), I had the privilege of touring the province. The tour was during flu shot season, so I took the opportunity to meet many Public Health physicians and staff. They are all good, hard working people who are dedicated to their communities and doing their best to advocate for the health care needs of the population.

Unfortunately, the Public Health system in Ontario (and Canada) is fragmented and disjointed. This really impeded the ability of Public Health to act in a unified manor prior to the pandemic. But because Public Health wasn’t as “visible” at the time, the flaws in the system remained hidden.

To understand just how this fragmentation affected our health, one only looks at the situation around trans fats. I wrote about this previously, but in short:

– We’ve known since 1993 that trans fats are linked to increased heart disease

– We’ve known since 1995 that Canadians are one of the highest consumers of trans fats in the world

– Denmark, led by their strong public health system, essentially banned trans fats in 2004 and within 2 years had 4% less deaths from heart disease. There was also a reduction in childhood and adolescent obesity.

– The results were so good that many other European countries followed suit.

If we apply the Denmark results to Canada, we could prevent 600 heart attacks a year. Banning trans fats would seem to be a no-brainer, and clearly the type of thing Public Health should effectively advocate for.

But here in Ontario, outside of the City of Toronto trying to ban trans fats in restaurants in 2007 not much has been done about this. Part of this is because Ontario has 35 different Public Health units, who all function independently. They may not even have the same software when collecting data, and some still use paper charts. Because they all function independently, just because Toronto Public Health wants a ban, doesn’t mean all the other units would even know about it, much less share information on it, or advocate for it. And of course, every Province and Territory has their own autonomous Public Health System.

So essentially, the Public Health Units were unable to co-ordinate around this issue, and outside of trying to ban Trans Fats in school cafeterias, and a failed voluntary guideline by Health Canada, not much has happened.

It wasn’t even until 2017 that Health Canada got around to proposing a ban on trans fats, and 4 years later this still hasn’t happened. It’s worthwhile noting that over 10,000 heart attacks could have been prevented if we had acted at the same time as Denmark.

If in “normal”, non-pandemic times, the Public Health system was so fragmented, and disjointed, that something this straightforward couldn’t be accomplished, how would they perform in a once in century pandemic?

The answer, sadly, is not very well.

Just as the various Public Health Units couldn’t co-ordinate on the same message for Trans Fats, it appears the various units can’t co-ordinate on the same messaging around COVID. Case in point, on Nov 4, 2020, Health Canada finally (!) announced that yes, indeed, the coronavirus has airborne spread, and all facilities should take airborne precautions.

Dr. Theresa Tam, Chief Public Health Office of Canada announcing COVID19 was, indeed spread by aerosols

Yet a look at the website for my Public Health unit (Simcoe Muskoka) on Jan 10, 2021 (2.5 months later!) still shows the same guidelines that’s before the announcement. Namely, that the virus is spread through droplets and so cleaning surfaces is more important.

From Simcoe Muskoka Public Health, Jan 10, 2021.

So here we have two different messages coming from public health authorities.

By comparison, take a look at Japan. Japan decided back in February 2020 that the virus was aerosolized. They too have many regional public health offices, however, the regional branches send the information to the national office, and the national office makes decisions. Those decisions are clearly communicated to the public, so the same message goes through the country.

They very quickly focused on things such as air purifiers with HEPA filters in rooms, improving ventilation by leaving windows open (even in the crowded community trains) mask wearing, and improved HVAC systems.

A diagram showing Japan’s process for dealing with COVID19, part of their submission to “Environment International” – September 2020 edition.

As a result, on a per capita basis, Japan has only 1/8th the number of infections, and 1/14th the number of deaths from COVID19 as we’ve had in Canada so far.

But it’s not just messaging that’s the problem. Public Health Units are hampered by their archaic systems from adequately preforming the test/trace/isolate process so important to controlling the spread of COVID19.

My practice is close to the border of the Simcoe Muskoka District Health and the Grey Bruce Health Unit. If one of my patients comes down with a reportable illness, I have to figure out which health unit to report to. But they use separate forms. Additionally because they use separate data systems, they can’t share information between the two.

Supposing one of my patients were test to positive for COVID-19. What if they live in Grey Bruce, but work in Simcoe Muskoka. Who should I report this to? And more importantly who is responsible for the contact tracing considering they work in one area and live in another? Especially since they can’t share data.

The result? Effective test/trace/isolate does not occur in Canada.

Compare this to South Korea. South Korea has multiple regional offices for public health, but they’re integrated by the Korean Ministry of Health and Welfare (KMHW). They share software, and so can share data and information.

By having all of Public Health integrated, South Korea was able to have one source for information. So not only did they have a consistent message (the KMHW gave two press conferences a day), but they were able to effectively test/trace/isolate.

On a per capita basis, South Korea has only had 1/13th the number of COVID cases as Canada, and 1/20th the number of deaths.

Canada’s response to the COVID pandemic is among the worst in the world. Only the fact that we are next door to a country that has had arguably the worst response in the world seems to prevent Canadians from recognizing this fact. If there is one learning that me must take forward from this, it is that lack of an integrated, seamless and co-ordinated Public Health system has cost us many lives.

As a country, we need to support the people working in Public Health by improving the systems they have, so they can protect us in the future.

Note: This blog is based on the first part of a presentation I gave to the Public Health Youth Association of Canada (my thanks to them for asking me to speak). If you are suffering from insomnia, or if you are generally good person and want to support young people who are keen to improve the world, feel free to watch the presentation here:

We Need to Learn to Live With COVID-19

“All of this has happened before, and will happen again.” – Lt. Kara Thrace, aka Starbuck, from the Battlestar Galactica (2004) TV show.

An advantage of being old is that whatever is happening, you have likely seen it, or something like it before. Every so often, society undergoes an upheaval and people have to change behaviours. For those of us who were around in the 1980s, there are some stark parallels to what happened then, and what society must do now in 2020.

The early 1980s were a different time not only for how we lived as a society, but for how medicine was practiced. This was particularly true with how we handled body fluids. As surprising as it may be to some younger readers, there was no such thing as universal body fluid precautions back them. If you had a known blood born illness like hepatitis, then sure, extra precautions were taken. But not for every body. When I was in medical school, there were multiple stories of a particularly nasty vascular surgeon who would squirt blood on trainees during surgery if they got an answer wrong to his questions. Needle prick injuries were routinely ignored. There was not a robust sharps disposal system. In short, it was very different.

A huge shift in society, and medicine, came when reports of a novel virus (sound familiar?) became publicized. This virus was new, deadly, and little was know about it. At first, this strange new illness seemed to only affect gay men. This led to all sorts of additional discrimination against the gay community, and even more ostracization then they were already experiencing. Mainstream media outlets routinely referred to it as “The Gay Plague” which clearly didn’t help matters. This also led to whack job conspiracy theories about its origins, some of which persist to this day.

This strange new illness was, of course, eventually named “Acquired Immune Deficiency Syndrome” or AIDS and the virus that causes it was identified (Human Immunodeficiency Virus or HIV). It was recognized that body fluid transmission could spread it and that it was not limited by sexual orientation. We learned it was possible to carry the virus and not have symptoms and you could get it from anyone.

And so, the age of universal blood and body fluid precautions began, and policies around this were implemented in hospitals and other health facilities between 1985-1988.

But there was also a shift in how society responded. Until then, most public service announcements around Sexually Transmitted Disease (like this painfully dated one from 1969) focused simply on encouraging people to get treatment after the fact. And accepting that it was possible for you (yes, sweet innocent you) to get an STD.

AIDS changed all that. Suddenly, an STD could be deadly. Suddenly there was no cure or vaccine. Suddenly, just getting treatment wasn’t an option, and education around prevention was mandatory.

With education, the public took precautions. “No glove, no love” was a popular catchphrase used to promote latex condom use as these were proven to significantly reduce the risk of transmission of STDs (including HIV). Public service announcements shifted to openly talking about prevention.

In short, people and society adapted, and changed behaviours to deal with this new virus.

Today of course, we are faced with a novel new virus, that is clearly deadly and is widely publicized. Little was know about it at the start, and we continue to learn about it. The virus seems to have originated out of China, and this has led to all sorts of anti-Asian racism (including from the President of the United States). There are whack job conspiracy theories about it. As we learn more about the virus, we know asymptomatic spread is possible, and that, yet again, anyone can get it. There is no vaccine (and despite Dr. Fauci’s optimism I’m not holding my breath) and no effective cure.

In response, hospitals and other health facilities are implementing new polices around Personal Protective Equipment (PPE). Hospitals are taking extra precautions around elective surgery as the risk of mortality in patients who get COVID19 infections peri-operatively is ridiculously high. In my office I now see patients wearing a mask, eye protection, and surgical scrubs that I immediately remove after my day is done.

And now too, society will be asked to change in response to this most awful virus. The simplest thing to do of course, is to wear masks when you are in an indoor public place, or better yet whenever you leave the house. As mentioned in an earlier blog, one only has to look at Japan where there was poor social distancing, packed public transit and no closure of their famous karaoke bars, but people wore masks, and the number of infections was extremely low. Wearing them also is key to restarting the economy so we can get on with our lives.

Next, we need to accept contact tracing. Aggressive contact tracing in South Korea was largely responsible for their low rates of infection. I was glad to hear that Ontario will be introducing an app to do this. I can already hear the cries of invasion of privacy, but if we are to control this virus, we are going to have to figure out a way to contact trace safely, and protect personal privacy at the same time.

The big difference between the AIDS epidemic of the 1980s and COVID19 now is, of course, the economic costs. The economy was never shut down then, and the kind of wholesale level of job loss we are experiencing now in (hopefully) once in a life time.

But if we are to get the economy running (and we must for a whole bunch of reasons, including the fact a good job improves overall health care), then society will need to adapt again. We did it forty years ago, and I believe we can do it again.

I am however, not looking forward to 2060…….