#medicine – Page 7 – justanoldcountrydoctor

OMA, CMA and CCFP Should put MEMBERS, not the Corporation, First

My thanks to Dr. Paul Hacker, pictured here, for his contributions to this blog. Dr. Hacker is a former Vice-Chair of OMA Council and a former member of the SGFP Executive. He’s a strong advocate for physicians interests, exceptionally well versed in governance and bylaws, and good friend.

As we approach election season for the Ontario Medical Association (OMA), many members have regularly brought up one issue to me. Is it true that the the Board Directors for the OMA are all asked to sign “an oath of loyalty to OMA central and not the members?”. The question is usually asked with incredulity and a tone suggesting a disappointing response.

The OMA is a corporation, as is the Canadian Medical Association (CMA) and the College of Family Practitioners of Canada (CFPC). There are many, many good reasons for these organizations to be incorporated, including preferential tax rates, some indemnification for members from assuming the debts of the corporation in case of financial difficulty and a requirement that bylaws and Boards adhere to certain standards.

If you think your membership fees are high now – just wait till you see what they would be if these organizations did not incorporate.

Good corporate governance demands that Board Directors of any corporation put the fiduciary interests of the corporation first. So yes, when I became an OMA Board Director, I did have to sign an agreement saying I would act in the best interests of the corporation. “Oath of loyalty” is a bit hyperbolic, but Directors are legally bound by their fiduciary duties.

In order to help educate Board members on their role, governance training is provided to them when they assume their role at the OMA. I assume this is also the case for the CMA and CFPC. The governance training is usually provided by some hot shot consultant (we got some guru from Rotman Management). Given the consultant’s list of degrees/publications after their name, there was an understandable (but still irksome) tendency for the staff at the OMA to value their opinions on Board matters over some Directors.

But this whole thing is frankly a crock when we are dealing with a membership representing organization (I told our consultant that). Fiduciary responsibility as Director of a for profit corporation whose goal is to increase share value is fine. But it’s quite another when the raison d’être of a corporation is to be a non-profit whose purpose is to advance the interests and needs of the members.

Let’s look at some examples.

I previously wrote about the atrocious 2016 tPSA between the OMA and the Ontario. What I didn’t mention is that that tPSA was actually really good for the OMA as a corporation.

No seriously. The agreement, if passed would have ended a period of internecine warfare between the dismal Kathleen Wynne Ontario government and the OMA, saving a bunch of money. More importantly, that agreement also created some bilateral tables where the OMA could be a joint partner and “co-manage” aspects of the health care system with the government.

There was to be a table on recommendations on physician supply and distribution. One to “co-manage” expenditures of the Physicians Services Budget. A commitment to work together on health reform and much more. In short, that agreement would have given the corporation of the OMA more power and a say in the health care system. All the OMA had to do was ruthlessly stab its members in the back.

Yet look what happened in the aftermath. The then Board was thoroughly repudiated in the ensuring vote. The first non-confidence motion in a OMA Board Executive occurred. Multiple special meetings were called. The resignation of the executive led to a protracted period where the OMA had no leadership or spokesperson. This is good for the corporation?

Want more? Let’s look at the Canadian Medical Association (CMA). In 2018 the CMA surprisingly announced that it was selling MD Management, which many of its members had relied on for their retirement planning. It’s hard not to see why they did it. The CMA got upwards of $2 billion dollars for the deal. The corporation of the CMA clearly benefited significantly and, unless it is financially managed by the same crew that ran Enron (remember them?) – will never go bankrupt and will live in perpetuity.

All it had to do is, you guessed it, stab its members in the back in a move that was widely viewed with a sense of betrayal. The outcome? In 2018 when Dr. Gigi Osler took over as president of the CMA, it boasted 85,000+ members. When Dr. Lafontaine took over in 2022, that number dropped to 68,000. I asked a friend of mine who is quite high up the chain at the CMA what that number is now and she told me she tried to find out, but apparently “they don’t give that number out any more.” Hmm.

NB: I realize correlation does not equal causation, but I find it interesting that the CMA stopped saying how many members it had after a grumpy miserable old coot pointed out the drop in numbers last year. The Medical Post often reprints my blogs – perhaps one of their intrepid reporters could ask the CMA how many members they have today.

Once again, the question needs to be asked, how does a drop in members truly benefit the CMA? How can they honestly say they “champion the medical profession” when they have fewer and fewer doctors as members?

We are seeing the same thing unfold with the College of Family Physicians of Canada (CFPC). They recently announced the truly idiotic suggestion that it was fair to raise their membership fees by 7 %, and the even dumber suggestion that the residency should increase to 3 years from two. They are now embroiled in a serious controversy over this and their annual meeting promises to be a mess. (Both of these moves would benefit the corporate CFPC of course – but not the members or the public).

The pattern is abundantly clear. When Directors of membership corporations don’t put members first (not the corporation), the corporation will suffer. I hope whoever runs for Director of the OMA has the intestinal fortitude to politely confront whatever “governance consultant” is brought on, and tell them just that.

How To Stop the CFPC’s Plan to Increase Residency to Three Years

PLEASE NOTE: This blog has been updated with new information, and to remove an unfortunate aspersion that was cast on the administrators of the PFI Facebook group.

Recently, the College of Family Physicians of Canada (CFPC) announced plans to increase the Family Practice residency to three years. This is, in my opinion, the stupidest decision they have made in my 31 years of practice. They should fix the current residency program instead. They also announced plans to increase the fees that family doctors pay by 7%, at a time when most family doctors are struggling to stay afloat. This would be the second stupidest decision the CFPC has made in my 31 years of practice.

There is, however, some hope. Some members have gotten some private members motions onto the agenda for the CFPC Annual General meeting. If enough ordinary members vote for those motions, it will pressure the CFPC Board into doing the right thing and stopping the implementation of these changes. In typical Ivory Tower fashion, the CFPC has made the voting process exceptionally convoluted. It’s so labyrinthine that it made we wonder if it was done on purpose to discourage members voting. Ivory Tower types don’t usually like listening to the masses.

However, a step by step detailed set of instructions on how to vote down these proposals were posted by Dr. Liz Zubek on her Facebook page. Dr. Zubek stresses that this is an accumulation of information gathered by many doctors and she herself has copied and pasted much of it to form the final set of directions.

Dr. Liz Zubek, family physician from Maple Ridge BC. Dr. Zubek posted instructions on how to vote at the CFPC Annual General meeting.

Dr. Zubek forwarded to me the detailed instructions that the CFPC doesn’t want you to see on my blog. Here’s how to vote ONLINE and IN ADVANCE of the Annual General Meeting. You do not have to attend in person and can do it from your comfy (?) office chair.

From Dr. Zubek’s Facebook page:

There is an ability to vote down the 3rd year of residency with private member motions buried in the agenda for the upcoming CFPC AGM, plus the ability to vote for transparency asking the CFPC to post something as simple as board and committee minutes, so we can actually see how they come to their decisions that make no sense to us …..and we can also vote on their wish to increase our yearly fees. But it isn’t easy to vote!

These are instructions for how to vote by proxy in advance in the CFPC annual member meeting taken from another post: How To Vote, CFPC 2023

1. Find the two emails from Oct 11th called “1 of 2” and “2 of 2” (search “Participate CFPC” if you’ve already deleted them). Click where it says “Register here”:

2. That will take you to a new page. The “control number” to enter here is in the “2 of 2” email from October 11th . You may have to type it in because copy and paste hasn’t worked for a number of people.

3. Once you hit “Login”, it will take you to a new screen. Here, select “Yes, I wish to appoint a proxy”. This means you are registering your vote ahead of the meeting and don’t have to attend the meeting. (If you do end up attending, you are allowed to change your vote):

4. After you press “continue”, it will thank you and then send you two more emails that will take 20-30 minutes to arrive. NEW INFORMATION: Despite doing this 12 hours ago (as of this writing), I have yet to get a second email. Some physicians have told me it is now taking up to 24 hours to get an email. Many are complaining that they are having difficulty logging in in the first place.

5. Open the new “1 of 2” email and click on the weird looking “lumimeet” link and use the password that’s in the new “2 of 2” email to log in. Again, you may have to type it in because copy and paste hasn’t worked for a number of people.

6. You’re almost there! On this page, you can now click to read all the motions if you like. When you’re ready, you click the “Voting” tab at the top and you can…vote!

7. In the interest of democracy, I will not tell you how to vote. However I will tell you that I voted “no” to the fee of increase and “yes” to the next four motions for greater transparency, information as to how the 3rd yr decision was made, a financial impact report of the 3rd year, and to put a hold on 3rd year implementation. Hope this is useful! Now go and vote!! It’s so important.”

You MUST vote by MONDAY OCTOBER 30, 2023 at 5:00 pm!

My two cents:

This grumpy old country doctor intends to vote exactly like Dr. Zubek did. No to the fee increase. Yes to the next four motions. It’s unclear at this time whether these motions are binding on the CFPC Board. But at the very least, us ordinary members have to say our piece.

My initial blog, which I do believe was factual, commented on the fact that this post had been deleted from the Facebook group PFI by the administrators. The author had also been removed from the group. The way I wrote about it unfortunately cast aspersions on the administrators of PFI. That was inappropriate on my part and for that I am truly sorry. My goal was to comment on the fact I felt (and do still feel) it was inappropriate to remove a member without warning, but the initial way it was written suggested something more. That was wrong of me. My apologies again.

But one thing at time. Vote to stop the 3 year residency and fee increases first. Then let’s find out how the situation became so unseemly so quickly.

We Should Return to the Health Care Model Tommy Douglas Envisoned

In 2004, the CBC surveyed Canadians to see who would take the title of “The Greatest Canadian.” The winner was former Saskatchewan Premier Tommy Douglas. Douglas is widely, and correctly viewed as the founder of socialized health care in Canada.

His selection speaks not only to the dramatic impact he has had on this country, but just how much Canadians value health care. I will dispense with calling it “free health care” because that just isn’t true. Our tax dollars pay for it. But those dollars are supposed to provide care for all those who need it.

Tommy Douglas, the Greatest Canadian, and the founder Medicare.

As our health care system continues to collapse all around us, it’s worthwhile, I think, to look back at the type of health care that Douglas envisioned. The truth of the matter is, that it is quite a bit different than what we have today. And I think, is not at all what Douglas would want.

According to “The Canadian Encyclopedia“, Douglas’ views on health care were shaped by a number of events in his early life.

As a six year old, Douglas fell and cut his knee. Unfortunately, he developed osteomyelitis ( a bone infection) and the consequences hampered him for his entire life. He had numerous operations and at one point doctors in Winnipeg considered amputating his leg. Fortunately, a well know orthopaedic surgeon (Dr. R. J. Smith) offered to operate for free, so long as Douglas allowed medical students to watch. This saved Douglas’ leg, and helped convince him that health care should be readily accessible to everyone.

Later, as a young man, he moved to Weyburn Saskatchewan, and was dismayed by the complete lack of medical care. He buried a 14 year old girl who died of a ruptured appendix because she couldn’t get medical care. He also vividly told of burying two young family men in their 30s, who simply couldn’t afford to get medical care.

These experiences helped to shape his belief that we could do better as a country. I would suggest that all Canadian should share the belief that one should not have to choose between going bankrupt (or dying) and getting basic medical care.

As premier of Saskatchewan, he implemented the Saskatchewan Hospital Services Plan covering the needs of patients admitted to hospital. In 1961, he implemented the Saskatchewan Medical Care Insurance Act, that provided medical insurance for all residents of Saskatchewan. This of course eventually led to other provinces and the Federal Government adopting similar programs.

The wording is important, and I think speaks to what Douglas was trying to achieve, and frankly, where I believe we need to go back to. The plan was “Insurance”. With all the benefits, AND RESPONSIBILITIES that go along with insurance.

Here’s the thing. In Canada, ever since the Canada Health Act, we have really deviated far from what Douglas really envisioned. He never ever wanted a system where you could go to any health care provider and get assessed without any responsibility on your part. Indeed, he spoke to that quite eloquently in the Saskatchewan Legislature on October 13, 1961:

“I want to say that I think there is a value in having every family and every individual make some individual contribution. I think it has psychological value. I think it keeps the public aware of the cost and gives the people a sense of personal responsibility. I would say to the members of this House that even if we could finance the plan without a per capita tax, I personally would strongly advise against it. I would like to see the per capita tax so low that it is merely a nominal tax, but I think there is a psychological value in people paying something for their cards. It is something which they have bought; it entitles them to certain services. We should have the constant realization that if those services are abused and costs get out of hand, then of course the cost of the medical care is bound to go up.”

Douglas intuitively grasped that if people perceive something as “free” they will start to lose their sense of using it responsibly. That’s why the initial Medical Insurance Act was just that. A form of insurance funded by the taxpayer, and like all forms of insurance, there was a deductible and reasonable limitations.

People were able to now access health care, for a small fee that allowed them to recognize that they too had to take some responsibility for how they used the system. They also had to realize that not everything was covered. Basic health care yes. Options like wanting, say, a private room instead of a ward bed in hospital – well that would be an extra.

There are many problems with the Canada Health Act. But the most fundamental is that it is based on the premise that you can endlessly get something (in this case health care) for nothing. Gutless politicians (from all parties) continue to promote this mantra in never ending attempts to woo votes as opposed to, you know, actually telling the people the truth. Namely, that people should take some responsibility for how they use the health care system.

By continuing to perpetuate the the lack of accountability, our cowardly politicians have created a culture of entitlement instead of a culture of empowerment. Many (not all) people believe that they should be able to get all manner of testing because it’s “free”. I’ve been blessed to have a very pragmatic practice in general, but even I have had to tell people that I will not be ordering the serum rhubarb levels their naturopath wanted because it would be “free” if I ordered it instead of them, or the full body MRI that some “wellness consultant” asked for.

It’s time to bring some patient accountability back to health care. And the first step in that would be to go back to the model that Tommy Douglas had proposed all along.

Dear OMA Board Member, About That Mandate for Negotiations

Dear OMA Board Member,

I read, with interest Ontario Medical Association (OMA) Board Chair Dr. Cathy Faulds update last Friday. There’s the usual information in there about the goings on at the OMA (which sadly not enough members pay attention to, though they should). Critically for most members however, was this comment by Dr. Faulds:

“The board will hold a special meeting at the end of September to finalize the negotiations mandate for use by the Negotiations Task Force (NTF)..”

This is a big step in the negotiations process and to truly understand that, members need to understand what a “mandate” is. Allow me to briefly expand on what Dr. Faulds wrote. The short version is that a mandate is the minimum offer the NTF can accept from the government. If the government offers an increase that is equal to or exceeds the mandate, then the NTF will automatically accept that offer on behalf of the Board.

The corollary to that, which some Board members did not understand when I was on the Board, is that if the mandate is met, and the NTF accepts – then it will automatically mean that you as a Board have to accept the offer as well. As per Board rules, you will then have to endorse the government offer to the membership. You can’t very well tell the NTF “you must achieve XYZ”, and if they do achieve XYZ, turn around and say it’s not enough.

Therefore, it is incumbent on you as a Board, to make sure the mandate is sufficient for the membership as a whole, given the times we live in, and the environment around us.

To that end, without spilling specific secrets, I will state that there was quite a lot of discussion about what an acceptable mandate was during my time on the Board. There were some Board Members who wanted to be “reasonable” and some who wanted to take a hard line and keep the mandate high.

I would, respectfully, point out that for the most part, mandates are never met. Usually the NTF comes back to the Board with “we tried – but this is the best we could get” and presents that to the Board. To be clear, I’m referring to all labour negotiations in general, not just physician ones. Negotiations Legal Counsel told us this last time, just ask them. Whatever you (or any Board) sets as the initial mandate, there is a strong chance the NTF will come back to you later and ask you to lower that mandate.

You will need to keep that in mind when setting your mandate.

To that end, I would encourage you to recognize that the time really has never been better to set the bar extremely high for the NTF mandate. It’s not just that physicians are considering leaving the profession. It’s not just that health care is collapsing all around us. It’s not just the ongoing problems with not just recruiting, but retaining physicians. You already know about all of those issues in excruciating detail.

No, the reality is that we now also have some significant competition for physicians within Canada from other provinces. And I mean strongly significant.

Not sure how many of you have seen this summary form the recently approved Physicians Services Agreement (PSA) in Nova Scotia. On the surface there would appear to be a fairly minimal 10% raise over four years. A deep dive however shows significant add ons like improved parental benefits, funding for overhead, funding to hire allied health care professionals, funding for admin work, enhanced FTE and income stabilization for specialists and so on. That plus a retirement fund!

Similarly, in Manitoba, their recent agreement was widely hailed as a landmark and a game changer. I spoke to a friend of mine from Manitoba who confirmed that it too contains things like a retention bonus ($21,000 and higher for those in rural communities), funding for admin time, funding for new models of care, additional funding for those patients who are older and an equity lens applied to fees. In short, the increase is widely viewed to be in the double digits percentage wise per year.

Look, I know the NTF knows all the stuff I’m pointing out (but others who read my open letter may not). I also would acknowledge that Dr. Mizdrak is a fine chair for the NTF and is (in a very good way and said with total admiration on my part) a real pitbull on behalf of the profession. I also have full confidence that the NTF did it’s due diligence in reviewing the many asks by the leaders of all the specialties.

But at the end of the day, it is up to you, dear Board Member to set the minimum acceptable deal (mandate) and it is up to you dear Board Member to ensure that Ontario remains a competitive place to attract physicians.

To that end, you must ensure that if there is a negotiated agreement, it must at least equal the increase in Manitoba or Nova Scotia (whichever is higher). Anything less would, quite frankly, be rightly viewed as the Board selling the profession out. (If we wind up going to arbitration, that’s a different story – but at least we will have gone there because the Board refused to take a sub optimal deal).

All of which is a long way of saying that since it is quite likely that an initial mandate may not be met, it is incumbent on the Board to set a mandate for the NTF that is HIGHER than what was achieved in Manitoba/Nova Scotia. This will allow for the usual process of the NTF having to come back and say what parts can be achieved and what can’t, and allow some wiggle room.

If you set the bar lower, well, frankly, I have to wonder how you can justify saying that you are advocating for the Doctors of Ontario.

Yours truly,

An Old Country Doctor.

RePost: Inside Ontario’s Bloated Health Care Bureaucracy

NB: This is a copy of a column I originally wrote for Postmedia in October of 2015. It’s copied here so that I can access it easily in the future. And a sad reminder that as of 2023, things haven’t changed for the better. If anything, they are worse.

Ontario’s health-care bureaucracy has exploded over the past 12 years, mostly because the government has set up a series of arm’s-length agencies it can scapegoat.

I’ve experienced this bureaucratic mess first-hand.

From 2013 to early 2015, I was the lead physician for the South Georgian Bay Health Links. I took the position because I was told the goal was to co-ordinate care between various health-care agencies to better help patients with the most complex illnesses.

Then-health minister Deb Matthews said there were too many “silos” in the health-care system and anointed her then-associate deputy minister the “silo-buster.” The ADM told us to develop a local solution — because each area is different — and focus on our strengths to help these patients.

Our area is very fortunate to have an advanced IT infrastructure. Virtually all 60,000 residents have an electronic medical record (EMR) in a joint database. We are also one of only two regions in Ontario with electronic prescriptions. This process requires the pharmacy to have a portal that allows it to communicate securely, in real time, with the physician to discuss issues of clinical importance.

My patients have benefitted significantly from this technology, so our thought was to set it up with other allied health-care providers (home-care nurses, retirement and nursing homes, community support workers, etc).

The Ministry of Health funded Health Links through the Local Health Integration Network (LHIN). So we put a proposal together and took it to the LHIN. The LHIN’s IT department liked the idea, but wanted to get input from the ministry. The ministry liked the idea, but wanted us to get the input of eHealth Ontario, the independent agency trying to create electronic health records. eHealth told us to come to a “regional network meeting.”

At the meeting, they thought the idea was good, but asked for the ministry’s eHealth liaison to comment. The liaison referred it to the ministry’s IT group (yes, the ministry has both an eHealth liaison group and an IT group) who wanted to ensure compatibility with a “provincial solution” — even though we were told to develop a local one — and suggested we review with the LHIN IT department.

After a year of “circling back” (a phrase I learned from these guys that I came to detest) we finally gave up, funded the project ourselves for $70,000 — less than a salary on the province’s Sunshine List — and my complex patients are now starting to see the benefits.

As I have come to appreciate, the government set up these various arm’s-length agencies, such as the LHINs, eHealth, Health Quality Ontario, Community Care Access Centres and so on, rather than simply have the ministry accept responsibility for these tasks. From a politician’s point of view, this gives them the ability to deflect criticism by saying such and such agency is “independent.” For the most part, this has worked for the Liberals. They’ve won four elections in a row. But it certainly hasn’t helped the patients any.

My colleague, Dr. Shawn Whatley, posted a superb blog piece that looks at how many bureaucrats work in Canada’s health-care system. It shows Canada has three times as many bureaucrats as other countries with advanced universal-care systems. Even worse, Ontario has only 1.7 acute-care hospital beds per 1,000 people, which is about HALF the average for other OECD countries. Ontario got to this number by closing 17,000 acute-care beds — and laying off the nurses needed to staff them — between 1990 and 2013.

But at least the bureaucrats are producing meaningful reports and are happy to be helping with moving health system transformation forward, right? Not so, according to a recent survey of health leaders conducted by Quantum Transformation Technologies. Most respondents said they aren’t happy with Hoskins or the LHINs.

It’s dramatic just how badly health leaders feel the system is working. The comments at the bottom of the survey are equally telling. There are repeated calls to cut the number of LHINs and reduce the size of the bureaucracy.

So in summary, Ontario is burdened with a bloated, ineffective, and demoralized health-care bureaucracy.

Wynne and Hoskins’ solution to this? Lay off nurses and start a fight with doctors over their fees.

Franz Kafka couldn’t have come up with something this convoluted.

— Mohammad Gandhi, MD, CCFP, FCFP, is an assistant clinical professor at McMaster and Queens universities.

* More than 1,000 doctors recently joined a Facebook group to complain about how the Ontario Medical Association, which represents them, isn’t sticking up for them in their fee fight with the province.

Earlier this month, the province cut funding for doctor services by $235 million, chopping doctor fees by 1.3%.

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GROWING HEALTH-CARE BUREAUCRACY

* There are 0.9 health-care bureaucrats per 1,000 people in Canada, compared to 0.4 per 1,000 in Sweden; 0.255 in Australia and 0.23 in Japan. Germany has 0.06 bureaucrats per 1,000 people.

* Ontario has only 1.7 acute-care hospital beds per 1,000 people, which is about half the average for other OECD countries.

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A recent Canadian Institute for Health Information (CIHI) report — the one Premier Kathleen Wynne and Health Minister Eric Hoskins say shows “Ontario has the best paid doctors in the country” — also says 12,000 Ontario nurses left the profession this past year.

* It also shows Ontario has only 176 physicians per 100,000 people (ranking 7th in Canada).

* Ontario has the fewest family doctors per 100,000 people out of all the provinces. Only 10% of family doctors in the province are accepting new patients.

* A recent Quantum Transformation Technologies survey of Ontario health leaders found 55% think Hoskins is doing a poor to fair job, 62% think the LHINs are doing a poor to fair job, and 50% feel the government has a poor track record of helping those with mental health issues.

Dear Premier Ford, You Know You’re a Conservative, Right?

Dear Premier Ford,

I’m not exactly your harshest critic. I actually support some (not all) of what what you’ve done in health care. Moving procedures from hospitals to outpatient clinics, building new hospitals, enhanced funding for paediatric mental health, are good steps. I hope there will be more commendable steps in the future.

Ontario Premier Doug Ford makes a health care spending announcement

However, I would be remiss if I didn’t point out that the health care system is going to be under a lot of fiscal pressure in the next couple of years. The remuneration that taxpayers pay for front line health care workers is about to increase drastically.

You will note, I hope, that I said “taxpayers” pay. I, like you in the past, try to avoid saying “government money”. The money to pay for health care and other services comes from the pockets of the little guy as a certain politician once put it. Calling it “government money” is just a way to deflect the public from the truth.

At any rate, you are no doubt aware that the nurses in Ontario got a well deserved 11 % arbitration award. You are probably aware that negotiations for a Physicians Services Agreement in Ontario are about to begin. Given that Manitoba just negotiated a record overall funding agreement with their doctors, and Nova Scotia doctors got a significant increase, you will not be able to hold the line against physicians getting an increase in Ontario.

Which of course means that many more health care workers will want an increase too. In short, there is going to be a lot of fiscal pressure on the taxpayer in the near future.

With that in mind, I will confess that my biggest disappointment in your management of health care is that I can’t honestly see that your government has reigned in the bureaucratic bloat that has so hampered the ability of front line physicians (and other health care workers) to look after patients properly.

Bureaucratic bloat is common in all government agencies. I greatly admire politicians who’ve made comments about needing to “end the gravy train” that provides jobs for bureaucrats and a myriad of consultants at the Provincial Government. Perhaps it’s because I live it daily, but no where does this gravy train seem to be so prevalent as health care.

Let’s look at digital health in Ontario for example. You have Ontario MD, which is an arms length agency that claims to be “the only truly provincial digital health network in Canada”, whatever that means. When I was on the OMA Board, OntarioMD was funded by taxpayers around $18 million a year.

But wait, you also have eHealth Ontario, that claims to be “creating a secure electronic health record information system so that all your medical information can be safely shared and accessed by your health care providers“. If I can decipher their audit statements correctly, they get a further $234 million dollars in revenue.

But that’s not all. The Ministry of Health has not one but TWO separate departments that appear to deal with health IT issues. Their organizational chart clearly shows a bureaucrat in charge of Health Services for an Information and IT cluster. She has her own team of well paid bureaucrats. Yet there is another bureaucrat in charge of Digital and Analytics strategy all with his own team of well paid bureaucrats. The Digital Health Branch of the Ministry of Health had a budget of almost $324 million in 2021/22.

And this is where the waste comes in. You have three agencies (one with two departments) to deal with one field, all reporting separately, none of whom necessarily agree with the other on what to do next. I saw this a lot at government when I was with the OMA. So progress was significantly impaired in digital health because not only was there not one vision amongst the agencies, but because every single issue went back and forth between the three agencies to try to get alignment (to cover the asses of the Sunshine List bureaucrats in case something went wrong). As a result, we are far behind every developed country (except the United States) when it comes to digital health.

I remember a politician who said:

“What drives me crazy is when you have a supervisor in government, and they report into 12 other supervisors. That’s unacceptable.“

That’s exactly what happens with the digital health care strategy in Ontario.

But moreover, the same thing happens in every single branch of the health care system. I mean seriously, if you already have a Clinical Care and Delivery Branch of the Ministry (see organizational chart) why do you need a separate arms length agency like Cancer Care Ontario? Or Ontario Drug Benefit? Or a myriad of others? They should be rolled up into the Ministry. There are many more examples but you get the point I hope.

If you were to simply stop funding OntarioMD (which in my opinion is no longer useful) and the scandal plagued, eHealth Ontario (which completely failed in its mission anyway), that would represent a savings of $250 million. At $100,000 each, that could pay for 2,500 front line nurses. Clearly nurses who provide front line care are more needed than bureaucrats who go around in circles.

The bureaucrats will no doubt fight you if you tried to do this. They will produce reams of power points and glossy manuals (all on the taxpayers dime of course) saying their work is important. But seriously, what would you expect from those who are accustomed to the gravy train?

Conservatives are supposed to be about reducing government waste, decreasing bureaucracy and efficient delivery of services. These are age old principles that, to be honest, I have yet to see from you as Premier.

If you don’t want to heed my advice, might I suggest that you instead take to heart the advice of the politician I mentioned above who wanted to end the gravy train and reduce the reporting to 12 other supervisors nonsense. That politician? A guy by the name of Doug Ford.

Respectfully submitted,

An Old Country Doctor.

#Docxit on the Rise, Means More Trouble for Our Health System

Acknowledgement: I want to thank my friend Dr. Graham Slaughter for coming up with the term “Docxit”. Graham is not only a brilliant internist, but is incredibly talented at wordplay and music. Plus, he has really thick, lustrous wavy hair!

A bunch of stuff has come to my attention recently in my social life and on my social media feeds. I’m saddened by all of these and even more saddened by what this means for the residents of Canada.

Item 1: a friend of mine in her early 40s confided she is going to give up her family practice. She loves her patients, but the admin burden and the poor remuneration make it no longer feasible to do this work.

Item 2: two more friends of mine, also in their 40s, are actively making plans to leave medicine altogether. One of them told me she knew four family physicians (all in their 40s) who left this year alone, and two others in their 30s who have moved out of country.

Item 3: I came across a social media post from a friend of mine from my days in OMA leadership announcing he was now a real estate agent. Amongst the people congratulating him on passing his real estate exams were other physicians also saying they were look at ways of getting out of medicine.

Item 4: The family health organization I’m part of in the Collingwood area has gone from 52 family physicians to 47 as some have retired without finding a replacement, despite trying.

Provincially of course, there are many more such stories. Three family doctors in the Ottawa area left their practices earlier this year. Twenty per cent of family doctors in Toronto are planning on closing their practices in the next five years. The list goes on.

It’s not just Ontario. British Columbia is facing a “dire picture” when it comes to family physicians. Doctors Manitoba, through their excellent (now past) president Dr. Candace Bradshaw, pointed out the need for more doctors on more than one occasion. I could probably find articles from every province highlighting issues with recruiting and retaining physicians, but you get the point.

Doctors, it seems, are looking at leaving the profession (for either retirement or other jobs) in alarmingly high numbers. This phenomenon, dubbed Docxit by Dr. Slaughter, is happening at a time when our health system can arguably least afford it (if it ever really could).

This is particularly a concern as our younger physicians seem to be more likely to quit. A report by Statistics Canada suggested that up to 47% of physicians with less that 5 years experience are intending to leave or change jobs in the next three years. To be clear, they are not intending to retire, just do something other than what they’ve trained for.

This phenomenon is not just present in Canada. The American Medical Association is concerned about “Medicine’s great resignation” as 1 in 5 physicians in the U.S. are also planning an exit in the next two years.

The situation in Europe would appear to be even more dire. The Politico article I linked to states that seven million people in France do not have a family doctor, with more family doctors retiring than setting up a practice. There is a shortage of two million health care workers in Europe. Brexit has badly worsened the shortage of doctors in the United Kingdom. Spain is running out of doctors. And so on.

Once again, those leaving appear to be over represented by younger physicians. It’s so bad that European Junior Doctors (an association of younger doctors in continental Europe) issued a press release warning the health care system there was going to collapse.

What’s going on then? Why are so many doctors leaving? I mean, despite the few (but loud) vociferous miscreants on social media, being a physician is still the most respected profession in the world (at 83% we’re tied with farmers and scientists). Studies show that Canadians trust their doctors to make the right choice for them and are afforded a measure of leeway that politicians and bureaucrats must surely be envious of. And you know that stereotype about first generation South Asian immigrants always wanting their kids to grow up to be doctors because of their status in society – it’s true (trust me, I and many of my friends lived it).

But the reality is that over the past ten years, practicing medicine has devolved to where it is no longer about caring for patients (which is what all good doctors want to do). In Canada, it’s been about fighting bureaucracy. With doctors now spending up to 19 hours a week doing paperwork (that’s a half a work week for most people) or fighting nameless, pointy headed, basement cellar cubicle dwelling bureaucrats to get them to actually pay for surgery that a patient needs, medicine is now more about who can do paperwork better than who can promote health care better.

In the United States, the rise of corporate entities eating up private medical practices has fuelled an explosion of a different kind of paper work, all with its own stresses. One study suggested that each physician spends almost $83,000 U.S. a year interacting with insurance companies.

Add to that the ludicrous number of options and waivers and liabilities and I sometimes think it’s easier to understand Einstein’s Theory of Relativity than it would be to understand U. S. Health Care. Dr. Glaucomflecken does an excellent job of explaining the frustration here:

I don’t know what the reasons for #Docxit are in Europe, but I imagine they are similar. The over bureaucratization of medicine is taking its toll everywhere. As was stated in the Politico article:

“At its core, it’s really that there is the perception that potentially medicine is no longer an attractive career choice, a choice for people to stay in for a whole career. And this will really endanger the sustainability of health care systems in future,” – Sarada Das, secretary-general for the Standing Committee of European Doctors (CPME)

There are so many crises in our health care system right now, it’s honestly hard to keep track. But two things are for certain. First, we won’t be able to fix health care without retaining doctors. Second, as more doctors opt for Docxit, we would appear to be doing a lousy job at retention.

Never Been a Better Time to Slash Bureaucracy, Inefficiency in Health Care

Recently, I was honoured to have been invited to participate in a debate hosted by the London and Area Muslim Healthcare Professionals group. The topic was a current hot button issue in health care:

“ Integrating private funding into Canada’s publicly funded health care system will help improve access, quality and equity“

I wound up having to speak against the motion, even though I actually do support the concept of increasing private sector involvement in health care with strong oversight. (I can already hear the usual suspects alleging I believe in “Two Tier American Style Health Care!”)

It’s a challenge to come up with ways to advocate for a position you don’t truly believe in, particularly when your opponent is the incomparable Dr. Saadia Hameed Jan. This woman is brilliant. Became a physician in an extremely patriarchal country (Pakistan), was an anchor on their national television service, then wound up doing more training in Canada and rose to the ranks of associate Professor at Western all the while maintaining a family practice. I had to be on my toes for this one.

Yours truly, and the amazing Dr. Saadia Hameed Jan

In the process of trying to figure out what to say, one fact continued to stand out in my mind. While one can argue about the merits of private funding, no reasonable person with any familiarity with our health care system could argue that it’s efficient.

During the debate I brought up the story of a patient of mine with cancer. She needed to see a surgeon, a medical oncologist and a radiation oncologist. When she got to the surgeon, the surgeon couldn’t access the actual imaging I had done (did have the written report, but any surgeon will tell you they want to see the pictures). The medical oncologist didn’t get the pathology report (fax machine blurred) and radiation oncology didn’t get a couple of things either.

All of which meant my patient had completely unnecessary delays in treatment. We all know that delays in treatment lead to worsened health care outcomes.

Yours truly desperately trying to hold his own at the debate.

Did the situation eventually resolve and my patient start treatment? Yes of course, after some running around and re-faxing of information and so on, but the point is that there was rather a lot of wasted time.

And that really was the genesis of my position in the debate. We have so many inefficiencies in our health care system right compared to other countries and all of that leads to waste.

Let’s look at a comparable patient in Turkiye. (Full disclosure – I do consulting work for Medicte, a medical tourism firm that provides cost effective health care services for Canadians in Turkiye). In Turkiye, my patient would have her entire health history accessible to her via eNabiz, an app on her phone that’s free to all citizens of Turkiye and allows them access to their health records. On going to see the surgeon, she would have been asked to consent to the surgeon looking at her health files, which would have allowed him, through his own software, to look at the images directly. The two oncologists could have gotten everything they needed right away as well.

Now take this patient, and multiple by 40 million Canadians, and just think of how much better everything in health care would work if we had such a system. No more specialists not getting full information. No more pharmacies losing prescriptions. No more need to repeat tests because you can’t access the tests that were done a short time ago.

Dr. Jan eloquently defending her position at our debate. (I cropped out the image of me sweating buckets!)

The really frustrating thing is that our politicians have known all along just how inefficient our health system is. Heck, Matthew Lister, a top health systems executive and now consultant wrote back in 2011 (!) that our health system had far too many bureaucrats. Back then we had 10 times as many health care bureaucrats per capita as Germany (!). Having watched health care devolve over the past decade, I dare say that ratio is worse now.

Just one example (albeit an important one) is the mess that is the digital health system in Ontario. The Ministry of Health has a digital health branch. Then you have a separate government funded arms length agency eHealth. But wait, there’s yet ANOTHER government funded agency, OntarioMD. This is complete nonsense. You don’t need three agencies to run digital health. Get rid of two of them already and have one unified vision for digital health.

I met with all three agencies during my term on the Ontario Medical Association Board and while it’s true that they are all staffed by nice people (except for one bureaucrat who’s a grade A prick), the reality is they often had competing visions for health IT and frankly, weren’t able to articulate a clear reason for their existence, or a vision for the province.

Now multiply this by all the other areas in health care and you get my drift. As Lister wrote:

“Our current health-care processes are lethargic, inefficient and unproductive. Excessive approvals (“courage in numbers,” in the words of one health-care administrator) hinder decision-making. Overproduction of documentation was cited as a necessary waste to accommodate the whims of bureaucrats.“

Health Systems and High Performance Operations Executive, Matthew Lister

This is why we have ridiculous situations in Canada like that of Christine Kaschuba, who’s had to wait years for badly needed scoliosis surgery, and now finds that she may not get it at all because the bureaucrats can’t decide whether or not to pay for the procedure.

Look, I realize that Canadians value our health care system and as such are always going to have strong opinions about the role of private companies in health care. But if we value health care so much, we should also hold our politicians to account, and ask them why we waste so much money on needless bureaucrats in the first place. Who would object to a more efficient health care system, where money is spent on doctors and nurses, as opposed to the loathsome bureaucrats who contribute to Ms. Kaschuba’s suffering.

Dr. Katherine Smart, past president of the Canadian Medical Association, said last year that the health care system is “collapsing all around us“. Surely if that’s the case, there has never been a better time for our politicians to show the courage, leadership and chutzpah needed to re-organize and reduce the health care bureaucracy and transform our health care system. Is that really too much to ask?

Dear CFPC Board, Provide Business Training to Family Physician Residents

Dear Board of the College of Family Physicians of Canada (CFPC),

There’s a whole lot of talk about the crisis in family medicine. Even the College of Physicians and Surgeons of Ontario felt compelled to do a cover story on this issue. I’m just a (not very) humble ordinary member of the CFPC, so I don’t need point out the ramifications to the health system to such learned members as yourselves.

I fully respect that it will take a multi-lateral approach to fix this. However, the impression one gets is that the CFPC is focusing on extending the family medicine residency to three years, from the current two. This expansion has even been presented as a possible solution to recruitment woes.

Nancy Fowler, executive director of the CFPC, states that the current program is “way too compressed” to deal with increasing complexity of health needs in Canada, changing technologies, and greater awareness of the health impacts of racism. In the same article, she also notes that residents have told her they would like more opportunities in different kinds of practices and settings (basically that they want the extra year).

I think these arguments are weak. The most learning I ever got was in my first year of practice. There is simply no substitute for being out on your own. Join a supportive group like I did, and you will be fine.

I do respect that the current training program may not be adequate. I’ve taught many residents myself over the past 25+ years. The amount of useless “clinic day backs” and forums, research days and “behavioural science modules” that the residents are asked to do has increased to the point where I wonder when the residents actually, you know, see a patient in real life. No wonder they may feel unprepared for having their own practice.

University of Toronto and McMaster – I’m looking at you.

But the solution to that is, you know, fix the residency program. Not extend it with a year of the doing exactly the same nonsense that made residents feel inadequate to practice comprehensive family medicine to begin with. All that would mean is that after three years the residents will still feel unprepared.

Also, have you considered that if you do increase the residency by a year, you will have one year where NO family medicine residents graduate into practice? Would you care to explain to everyone how that will help the current shortage of family docs?

Anyway, if you do increase the CFPC residency to three years, would you at least add some practical training for our younger colleagues to the residency? I believe they would benefit from two months of their third year being dedicated to learning about the business of running a practice. How to hire people. Employment standards. Performance appraisals for staff. Negotiating leases. Finding the best prices for supplies. And yes, how to maximize your billings.

All of those above tasks (and more) are absolutely essential to running a comprehensive family practice. Yet NONE of those are taught in medical school or residency. In fact, in many universities, the feeling one gets when one brings up the idea that we should teach something as simple as billing is that you have spoken of that which shall not be spoken of, lest the appearance be created that your desire to practice medicine might even in the smallest part be less than altruistic and rather more about a hedonistic desire to generate a fair income.

The horror, the horror!

And yes, McMaster and U of T, I’m looking at you (again).

These are practical business skills all of us absolutely need to run a practice and isn’t the point of residency to, you know, make the residents comfortable running an actual practice in real life? Additionally, the reality is that we now face the existential threat of corporatization in family medicine.

This is how it works. A corporate clinic, let’s call them The Haleness Infirmary goes to a young family doc. They whisper siren like inducements like “Let us do the business of medicine for you”. “We do all the admin work so you can practice the medicine.” “We believe in high quality patient centred health care you can trust” and other alluring catch phrases. These clinics are almost always owned by some large corporation. Let’s say in this case, a pharmaceutical chain called Buyers Pharmaceutical Bazaar. All to entice the young, business naive family doctor so sign up with their chain.

The Haleness Infirmary could care less about the doctor they hire, or the patients they serve. What they want is the gold mine of patient data. It allows them to create a digital profile of the patient to target you with ads to sell products, because, the patient is nothing more than a commodity to them to be exploited.

It’s absolutely true that there are privacy laws that prevent individuals from collecting your personal information. Funnily enough, those laws don’t apply to software or AI. Software can figure out a lot about you based on your spending habits (it’s why if you look up say mattresses on a website once, you get ads for mattress stores on your social media feeds for a week).

If you go to Haleness Infirmary, the software would identify you as someone who needs cholesterol pills, and therefore you would see targeted ads for cholesterol lowering products (all sold at a special discount at Buyers Pharmaceutical Bazaar) so you can buy more products (and get extra points if you enrol in their Choicest points program which collects even more of your personal data). Nice ecosystem.

Don’t believe this is their goal? When I was OMA President, one of the pressing issues for OMA Legal was the fact that doctors who left (or were asked to leave) these fancy corporate owned clinics– suddenly found they no longer had any access to their notes or patients’ charts (“owned by us and only for use by our employees – and you are no longer one”).

The holier than thou types that haughtily profess that they are better than us for not teaching basic business skills of course would be the first to be horrified that patient data was being used for marketing (gasp!) and making money (double gasp!). The irony that their own belligerent refusal to teach basic business skills drives physicians to these corporate clinics is, of course completely lost on them. It’s hard to see irony why your head is constantly tilted upwards befitting your lofty altruistic ideals.

Extend the CFPC residency to three years if you must. But for the love of Allah/God/Yahweh/insert deity of your choice, at least give our future colleagues an appropriate education that teaches all aspects of running a comprehensive family practice. You will be doing them, and patients, a huge service, whether you realize it or not.

RePost: Marcus Welby Couldn’t Handle Today’s Medicine

This blog originally appeared in the Huffington Post on May 2, 2016. Reprinted here so that I can keep track of my old blogs, and also to once again point out how warnings of a crisis in Family Medicine were ignored for years.

Recently, Globe and Mail columnist Gary Mason lost his family physician to retirement. In an eloquent post, he reflected on how much he was going to miss his physician of 22 years, and how difficult it was to find himself in the position of not having the family physician. Unfortunately, as he pointed out, a growing number of Canadians are finding themselves in the same position.

Understandably concerned about his predicament, and wanting to know what’s going on, he did what most reporters and politicians do to find out about health care. He asked a health-care policy consultant, in this case Steven Lewis.

As an aside, it never ceases to amaze me how when people want advice with what’s wrong with health care, they always turn to health care consultants. Why not just ask a physician instead? If I have a leaky faucet, I don’t ask a Water Flow Policy Analyst from the Ministry of Environment what’s wrong. I call a plumber.

At any rate, I happen to think that Mr. Lewis gave Mr. Mason some pretty bad advice. Mr. Lewis suggested that newer Family Docs were incentivized to “do less.” This led Mr. Mason to opine that “in other words, Marcus Welby is dead.”

While I agree the situation is complex, the main reason that younger family physicians are taking fewer patients has nothing to do with either a lack of dedication or desire to help their patients, but rather that medicine has become far more complex in the past 30 years.

The past 30 years have seen an exponential increase in the number of screening and preventive care tests, all of which the family physician is expected to order.

For example, when I took over my current practice 24 years ago, I recall looking at one patient’s chart, and seeing the notation: “April 26, 1990. Strep throat. Penicillin.” This was clearly all the family physician at the time, really needed to know. However, there is no way on God’s green earth that you could get away with such a note in this day and age.

Since the 1990s there been a number of regulations on documenting patient visits set by Provincial Colleges and physician funding agencies (eg. OHIP in Ontario). In principle, the rules are put in place under the very reasonable rationale that there needs to be some accounting for spending public funds, and that documentation will prove those funds were spent wisely. In practice, that means that even a notation for such a simple problem, requires a minimum of four to five sentences in the chart. All of which means that there is less time in the day to see patients.

Additionally, contrary to what Mr. Lewis has told Mr. Mason, the responsibilities of the average family physician has actually increased since 1990. The past 30 years have seen an exponential increase in the number of screening and preventive care tests, all of which the family physician is expected to order.

For example, we never used to do bone density test on men. These were exclusively a test done on women, as they were thought to be at higher risk for osteoporosis. The guidelines have changed and now men over 50 are also being tested based on certain criteria.

In the past week, I have had six bone density results, four of which came back with a diagnosis of “low bone mass,” which require the patient to be called back, and counselled on the importance of the intake of dietary calcium, and vitamin D, weight bearing exercise etc, to preserve bone health and reduce the risk of fractures as patients get older.

I happen to be one of the relatively few physicians in Ontario lucky enough to have a superb Nurse Practitioner working with me, and she is really enthusiastic about counselling patients about these type of lifestyle changes. As a result, I am able to get patients to see her to learn about these lifestyle issues while I deal with some more complex cases. I appreciate that this may seem to be a “clinic” to Mr. Mason, but it certainly does maximize the value of both my time and hers.

Similarly, we now screen (in appropriate patients) for aortic aneurysms, colon cancer, breast cancer, diabetes and several other diseases. All of which require more time per patient, and result in abnormalities found, which result in time required to address those abnormalities.

One of the benefits of having an electronic medical record system, is the you can program them to have the system remind your patients when they are due for appropriate screening test. This could never be done on the old patient’s chart.

Recently, a patient came in to see me with a sore foot. Marcus Welby would undoubtedly have looked at the foot, and wrote in the chart: “Gout. Indomethacin.”

In contrast, my note documents when the pain started, that there was no history of trauma, a review of previous blood work to check his uric acid level (a contributing factor to gout), whether the neuro-vascular status was affected, how far up the foot the redness goes, and his vital signs. To which I add, “Assessment: Gout, Treatment: Indomethacin.”

At his visit, I also looked at the reminder screen of his electronic chart. I’ve included a snapshot (with personal information removed) of what I saw.

So now, not only did I treat his gout, but I ordered all of the investigations this fellow was due for (he tends to avoid coming to see doctors). If you do this on enough patients, you will find abnormalities, which will then require follow up.

Lest you think I’m complaining, let me categorically state, all of this is a good thing. Reports have shown that investing in primary preventative care, is good not only for the patient, but also for the population as a whole. These are wise investments to make, as they prevent far more expensive complications from occurring in the future. It’s like that old commercial about getting your oil changed on time in your car. You can either pay a little now, or pay a lot later.

However what it also does a significantly increase the workload per patient per family physicians. Which means it is no longer possible for a family physician to look after the same number of patients as Marcus Welby did. It is not as Mr. Lewis was quoted as saying “A desire to do less”, rather the work per patient has increased.

I’ve generally enjoyed Mr. Mason’s columns in the Globe and Mail. I wish him well in his quest to find a family physician. If he moves to my neck of the woods, I would probably consider taking him on, if only because I rather enjoy funny stories and debating politics with people. As a bonus, I don’t drink, so Mr. Mason would not even have to give me the expensive bottle of scotch he promised. (I would however, demand some inside dirt on his fellow columnist and health care reporter Andre Picard!)