Tag: #ONpoli

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!)

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What if We Didn’t Lose the Doctors We Trained?

Canada is in the midst of doctor shortage. In particular there are at least 6 million Canadians with out family doctor. The situation is worsening. The most recent Canadian Residency Match for medical students applying to specialties, showed that there were 268 empty spots for family medicine after the first round. This is the highest number of unmatched family medicine positions ever. Medical Students, being really smart people, are viewing family medicine as a dead end specialty and avoiding it like the plague.

If only the boorish loudmouth who predicted we were heading in this direction six years ago and been listened to…..

Governments at both federal and provincial levels are taking steps to try to address this. In British Columbia, they have introduced a capitation based payment model for family physicians (think of it as salary + performance bonuses). Ontario has a model like this that had great success in the early 2000’s. The federal government pledged more spending on health care in the future. Ontario plans the “largest expansion of medical school education in ten years.” And so on.

But what would have things been like if successive governments didn’t drive doctors away from Canada in the first place?

Going back as far as the 1990s, inept governments have, over the years, done their best to make physicians feel unwelcome. The Bob (“I am super elite“) Rae NDP government of 1990-1995 in Ontario implemented the Barer-Stoddart report. This report decided “there were too many doctors” (I kid you not) and cut medical school enrolment by 10%. Three decades later we are still feeling the adverse ramifications created by that move.

Similarly, the disreputable Kathleen Wynne Ontario Liberal government went to war with physicians in the mid 2010s, led by her woefully incompetent Health Minister Eric Hoskins, and his inept sidekick, Deputy Minister Bob Bell. Those geniuses thought it was a good idea to CUT 50 residency positions (training for doctors) and only saw the light during a deathbed confession just in time for the 2018 election. In particular, Hoskins and Bell’s blatant disregard and borderline contempt for family physicians resulted in, as OMA Vice-Chair Audrey Karlinsky put it, 6 years of family medicine graduates not choosing comprehensive family medicine.

Do you think supporting hundreds of those young potential family docs then would have made a difference now when 2.2 Million Ontario residents are without a family doctor?

To prove that idiocy in health care management can occur with parties of all political stripes, the former Alberta Conservative Health Minister, the combustible Tyler Shandro, actually verbally attacked a physician at his home in Alberta, along with, you guessed it, going to war with physicians in his own province. Really helps to retain physicians, no?

In my first ever blog for the Huffington Post (seven years ago!), I pointed out to then Health Minister Eric Hoskins that 30% of my graduating class no longer worked in Ontario due to Bob Rae’s intransigence. I urged Hoskins to change his behaviour or that by the time of the next election, health care would be in a worse crisis and hinted his government would pay the price in the 2018 election. (I wonder if Kathleen Wynne regrets sticking with him as health minister for so long, despite the fact he was obviously not up to the task).

Admittedly, that’s one person’s recollection. Are there any statistics out there that show just how many Canadian trained doctors have left Canada? There are, although they are really hard to come by, and not as up to date as I’d like. Huge shout out to Dr. Mary Fernando for digging these up for me.

In 2000, the OECD published a report on the mobility of health care professionals. On page 50, it indicated that 19% of doctors born in Canada were working in other countries. Given the crisis we see in health care around us right now, do you think it would help if we could have retained those doctors in Canada?

But wait, aren’t we trying get international medical graduates (IMGs) to come to Canada? Ontario health minister Sylvia Jones did direct colleges to come up with a way to speed up the ability to get foreign doctors licensed. But it turns out we have trouble keeping them as well. A study on retention patterns of IMGs in Canada showed that 12% of IMGs were approved to practice in Canada between 2005 and 2011 LEFT Canada by 2015. While IMGs apply, we have trouble retaining them too.

Clearly, governments need to focus on retention of physicians just as much (if not more so) than recruiting new physicians. What can they do?

The federal government can do a couple of things to help. First it can heed the results of a poll taken by the Medical Post magazine (I voted just before closing and these were the results):

Doctors don’t have pensions and benefits mostly due to some weird federal tax laws. Changing these should be easy and offering pensions and benefits would be a strong way to retain physicians. Similarly, reversing the 2017 tax changes that completely threw retirement planning out the window for doctors would be a big help.

Provincial governments should of course, take note of the fact that going to war with doctors always leads to a deterioration in health care for the residents of their province. But since most politicians are incapable of thinking about anything but their own self interest, let me point out three facts.

In 1995, after going to war with doctors, the Bob Rae NDP government was turfed from power in Ontario and the NDP has yet to form a provincial government since. In 2018, after going to war with doctors, the Kathleen Wynne Liberal government was decimated in the Ontario election, even losing official party status, which they have yet to regain. In 2022 after going to war with doctors, Alberta Premier Jason Kenny had to resign as premier because his own party saw the writing on the wall.

The message is clear. Going to war with doctors is bad for health care and bad for political careers. It’s time politicians realized that, and came up with meaningful solutions like pensions to retain the ones we train.

Canada’s Health Care Landscape has Changed Since the Canada Health Act

I’m honoured to have Dr. Silvy Mathew guest blog for me today. She’s a former member of the OMA Board, former member of the Physicians Services Committee, has a Master’s in Health Policy and Economics, a Certificate in Global Health and is hands down one of the smartest people I know.

Health care in Canada is governed by the Canada Health Act, a federal act that essentially states that medically necessary care provided by physicians and hospitals, will be covered by public insurance and administered by each province. 

The Act was passed in 1984, and is reflective of the type of acute medical care practiced at the time. However, in 2023 (and for at least a decade prior), medical care, through technology, medical advancements and aging, has changed drastically. Publicly covered care now, however well intentioned, is sorely lacking. Ironically, because of that, it is also very expensive.

For exampe, we lack public pharmacare  for adults despite being promised this by 2006 by then Prime Minister Paul Martin. (There is some pharmacare for seniors and children).

We lack dental care. We lack appropriate home care in an aging population that is getting weaker and frailer. We lack coverage on physiotherapy. In an era of increasing mental health burdens we lack psychotherapy.

The list goes on and on, notwithstanding the severe social issues that contribute to many of these issues (healthy food, exercise, housing and all the other social determinants of health).

Because we have not invested upfront, we pay significant costs in expensive procedures, prolonged hospital stays, and medications much of which could be minimized or avoided.

Why does it matter?

McKinsey Global Institute published a prospective analysis of 200 countries, looking forward on the impact of 52 diseases over the next two decades to quantify the social and economic gains if health is made a priority by government and private sector.  They quantified the value of health to the economy and showed that if using the existing interventions we have today, we can reduce disease burden by 40% in the next 20 years and extend “active middle age by 10 years”. This translates to an economic return of $2-$4 for each $1 invested. That’s remarkable. 

What’s the hold up? The lack of foresight, upfront cost and political inertia is costing us.

We have a shortage of healthcare professionals, and we use the ones we have, in extremely inefficient ways. For example, the lack of a proper digital health infrastructure in Ontario (like they have in Turkiye!) results in duplication of services, poor coordination, and inconsistent delivery of health care. Even the electronic services we DO have don’t capitalize on Artificial Intelligence (AI).

Technology advancement is a double edged sword. There are benefits to patients in terms of ongoing updated guidelines for care. But health care workers are having to do more, monitor more and change practice styles more, all leading to more individual HCW time.

Each test, often results in further testing or reassessment down the line, which compounds the problem. It’s rare that physicians just close the door on one issue a day.

Again, at the time of the Canada Health Act, we were practicing acute, limited health care. Today’s world is focused on prevention and chronic illness with monitoring. That shift has placed a huge burden on physicians time to review, inform/educate, coordinate new referrals and remind individuals to do monitoring.  Much of the time, it seems like we still don’t know how much benefit we will get from this. Hopefully the data will show we were correct to do this.

To collect and review the data though, we would need better digital systems to capture the information, which we don’t have.

Some people imply this will be managed with more “healthcare team members”. I think a huge solution for this particular issue is investing in technology and AI solutions.

Right now, we are trying and failing at holding back an avalanche.  We have technological advancements, but limited access to those. We have lack of integration of our digital infrastructure. An ageing population is leading to increased needs. But an aging health care work force is seeing retirements and illness leading to less access. New providers are available but their impact is less clear due to lesser training and duplication of services leading to increased costs. Delayed diagnoses are leading to worsened health outcomes and more expensive care. There is less preventative care due to a shortage of family physicians which leads to delayed diagnoses, worsened health outcomes and more expensive care. Lack of care giver support and home care support means that people are leaving the workforce to care for ill relatives which leads to hospital dumping. Burnout is endemic in health care, due to a feeling of disrespect and an inability to practice best patient care.

And so, physicians are in all areas of the country are giving up and closing their practices.

In the meantime, while we wait for our wishes to come true, there is opportunity to push the envelope and to drive change. People are desperate and they want options.

When access to health care is inadequate, people will choose out of jurisdiction options for delayed procedures and even screening tests. There is a moral hazard involved. People are taking risks by going elsewhere under the assumption that they will be taken care of properly.

However, with any challenges, there are opportunities. Some “non-medically necessary” medical tests (eg. screening for vitamin D) are not covered by medicare. However, it’s increasingly viewed as an early intervention. We will only see technology increase these options as better screening methods become available, and governments delay paying for them. Perhaps instead of waiting for open heart surgery or stenting, there may come a day where preventative procedures can be used to dissolve plaque in the heart arteries.

Health care faces inescapable and exponential change. However, it is unlikely, at least in the near future, that Canada (or any country’s) public health system will be able to keep up with technology and demand.

Oh for some strong, principled leadership that can see these challenges and address them head on, without resorting to political sound bites.

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Federal-Provincial Health Care Deal Fails Canadians

This blog has been updated to reflect that the fact that the offer from the federal government has been accepted by the provinces.

Lots of chatter about what is an agreed upon funding formula for Health Care between the provinces and the federal government. Some astronomical dollars are being thrown around and called investments in health care. But at the end of the day, will this deal mean better health care for Canadians? The sad answer, is likely no.

One of the advantages(?) of being old is that you’ve lived through lots of things, and can see the past repeating itself. Case in point, in 2004 then Prime Minister Paul Martin introduced a health care “accord” that was designed to “fix health care for a generation“. Essentially the federal government ponied up an eye watering amount of money then, and the provinces were to implement targeted programs that would:

  • Reduce wait times
  • reform Primary Care
  • Develop a National Home Care program
  • Provide a National Prescription Drug Program (by 2006!)

Now Primary Care reform did happen in Ontario, with the development of capitation based payments to family physicians. Think of it as a salary with performance bonuses and you get the gist. There was also the implementation of some Family Health Teams. I’m unaware if any of these were implemented in other Provinces. I do note with interest that British Columbia is only now getting around to reforming primary care with their own new payment model for family physicians.

But both of these programs in Ontario were summarily slashed by then Health Minister Eric Hoskins and his servile deputy Health Minister Dr. Bob Bell in 2015. Indeed their unilateral freezing of the capitation model significantly damaged primary care in Ontario, and the effects of their folly are still being badly felt today by the 2 million residents of Ontario without a family doctor.

OMA Board Vice Chair Audrey Karlinsky put it best on Twitter.

Wait times for surgical procedures however, continued to rise, and I have no idea whatever happened to the National Home Care program.

For those of you paying close attention, the same Eric Hoskins who stopped Primary Care reform in Ontario, went on chair a federal advisory council with the goal of creating a National Prescription Drug Program……….in 2018. Which hasn’t been implemented yet. I suppose being 17 years overdue is not bad by government standards.

By the way, this whole process is basically recycling a failed politician to recycle a failed government promise. And politicians seriously wonder why average Canadians like me are so cynical??

So now, 19 years later, Canadians are being told that the provinces have accepted a federal government proposal to put an eye watering $196 billion into health care, according to Prime Minister Trudeau. But wait they were committed to $150 billion anyway so it’s really only $46 billion more, but wait, when you take out the planned budgeted increases it’s only $21 billion more. Whatever.

In return, for however much money it really is, Trudeau promises there will be “tailored bilateral agreements to address“:

  • Family Health Services
  • Health workers and the backlog of health care
  • Mental health and substance abuse
  • Modernized health care system

Our politicians need to study Albert Einstein a bit more.

Here’s the sad truth about our health care system that no politician, of any political stripe seems to be willing to admit. The system is dying and in need of radical surgery. It needs a bold, transformative vision that will completely change the way we deliver health care and will leverage technology appropriately. Anything less is simply more of the same, and will not stave off the inevitable collapse of the system.

How then do we achieve this transformation that is essential to the well being of Canadians? I will go into some further thoughts about this in future blogs, but first I would implore our political leaders to stop listening to old voices who have been advising for decades (if their advice had been good we wouldn’t be in this mess). It’s time to seek out some newer voices who have bright ideas on how to restructure health care delivery in Canada.

It’s also time to wrest control of health care data management from the current group of bureaucrats in charge of it. We can’t transform health care in Canada without a robust health care IT infrastructure and the current group simply is not getting it done.

As mentioned, I will put some more though into how, in my opinion, health care can be transformed in the future. But for now, just know that whatever the numbers or promises being tossed around, the blunt reality is that it all amounts to trying to spend you way out of trouble.

When has that ever worked out well?

Ontario’s Heading For Another Family Doctor Shortage

This is the follow up blog to my last one, originally published in the Huffington Post on June 13, 2017. 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.

The Barer-Stoddart report. Ask any physician of a certain age and the immediate reaction is likely to be disparaging. Written in 1991, it purported to help chart the course of the physician workforce into the 21st century. 

While it’s true that much of the report was ignored by the Ontario government of Bob “Super Elite” Rae, it’s still widely remembered for suggesting that the number of physicians in Ontario needed to be cut by 10 per cent. To accomplish this, medical school enrollment was slashed in the early 1990s.

Given that the population of Ontario continued to grow and age, the result was completely predictable. A massive doctor shortage (particularly in family medicine) hit the province at the end of the decade. It has taken the last 15 years to come close to correcting that. We’re not there yet (we still have fewer doctors per capita than Mongolia), but we were improving.

Alas, Ontario Health Minister “Unilateral Eric” Hoskins and Deputy Health Minister Bob Bellwere unable to remember the old saying, “Those who cannot remember the past are condemned to repeat it.”

Former Health Minister Dr. Eric Hoskins

Last week I blogged about how Hoskins and Bell need to support family medicine. Because they are not doing so, many physicians who graduate from family medicine residencies are not starting comprehensive family practices. Instead, they are doing things like hospitalist work, sports medicine and even medical marijuana clinics.

However, the situation is even worse than I thought. It was pointed out to me after my blog was published that the number of medical students applying to family medicine programs has dropped considerably this year. In Canada, to become a practicing physician, you first have to graduate from medical school, then do a residency (essentially a training program) in the specialty of your choice. To choose a residency, you apply to CARMs — which is a Canada-wide program that matches medical school graduates to the residency of their choice.

This year’s CARMs match shows some alarming results for family medicine in Ontario. Ideally, we should have 45 to 50 per cent of all graduates from medical school apply to family medicine for a sustainable workforce. However, only the Northern Ontario School of Medicine achieved that goal. While it’s a great school, it’s still the smallest of Ontario’s six medical schools.

By comparison, only 24 per cent of graduates of University of Toronto applied to family medicine, 27 per cent of Queen’s graduates, 32 per cent of Ottawa’s graduates, etc. Multiple studies show that comprehensive family medicine is responsible for decreased health-care costs, more efficient utilization of the health system, better patient outcomesand decreased hospitalizations. It is essential for a sustainable health-care system to have a strong family medicine component. The fact that so few medical school graduates chose family medicine, on top of the fact that recent graduates are not opening practices, should be setting off alarm bells.

So, why is this happening? First and foremost, it’s because Hoskins and Bell have refused to support family medicine. They have talked loudly about how they want to cut payments to higher paying specialties so that they could fund family medicine. Hoskins even went to the trouble of doctoring (pun intended) a chart to accuse specialists of overbilling. 

(Seriously, see the picture in this article. Notice how he made the pie chart on the right larger — the whole circle, not just the wedge showing percentage of billings. Makes the red area look LARGER than it really is, and makes the specialists look they are billing disproportionately more than they are.)

Unfortunately, while Hoskins and Bell were saying this in public, what they were actually doing is cutting family physicians. They unilaterally cut the number of physicians who could apply to the capitation (salary plus performance bonus) models of funding that I mentioned last week. This is the preferred method for paying physicians for newer graduates, and also for health care bureaucrats who like a predictable budget. Additionally, they cut a number of the performance bonuses family physicians got for looking after complex patients.

Medical students are not dumb. They saw all of this going on, and realized that family practice was no longer preferred by Hoskins and Bell. So they made career choices accordingly.

Currently, the Hoskins/Bell legacy is not a pretty one. It’s one of internecine disputes with doctors, laid-off nurses, hospital deficits, patients in stretchers for days and egregious wait times. At least with family medicine, they have an opportunity to begin to correct this mess by once again allowing new physicians to enter the capitation model, and restoring the various performance bonuses.

Failure to do so will mean that many years from now, as patients struggle to find a family physician, Hoskins and Bell will be remembered with the same disparaging legacy as Barer-Stoddart.

Hoskins and Bell Need to Support Family Medicine

The following is a reprint of an article that I wrote for the Huffington Post on June 5, 2017. Re-posting here so that we can see how the seeds of declining family physicians was planted by Drs. Eric Hoskins and Bob Bell, and also so that I can refer to it in the future if needed.

For the past 23 years, it’s been my pleasure to be a preceptor with the Rural Ontario Medical Program based out of Collingwood. As a preceptor, I have had the honour of supervising a wide variety of Medical Trainees, from first year Medical Students, all the way up to those in their last year of Residency. 

I often find I learn as much from them as they learn from me (it’s good to be questioned by students about why you do things the way you do). I clearly have some experience on my side, and they have more recent book knowledge. It’s a great combination for patient care.

Unfortunately, I can see that we are once again heading for the same situation as the late 1990s/early 2000s, when many medical trainees stopped going into comprehensive family medicine. The reasons then were due to increased workload, better opportunities in other specialties and an extremely poor relationship with the government of the day. 

At one point, only about 25% of graduates from medical school applied to Family Medicine Residencies. To suggest that there was a crisis in family medicine would be dramatically understating the issue.

However, the Conservative government of Mike Harris finally realized you need to co-operate with doctors if you want to improve patient care. In 2000, Health Minister Elizabeth Witmer rolled out something called Primary Care Reform (PCR) in co-operation with the Ontario Medical Association (OMA). This, over the next few years, led to a revitalization of Family Medicine, and now, close to 40% of medical school graduates are once again choosing Family Medicine as their specialty. 

While not the sole part of the PCR, a major component was a new model of paying physicians known as capitation. Capitation is essentially salary plus performance bonuses. Family Physicians would be paid a certain monthly rate to look after their patients, regardless of how often they saw them. They get bonuses based on how many complex (eg. Diabetic) medical cases they take on. This was in stark contrast to the old system known as Fee For Service (FFS) where physicians were essentially paid piecemeal (only got paid when they saw a patient).

The capitation based models were extremely popular with both Family Physicians and government. For Family Physicians, it allowed them to spend the time needed with patients during just one visit, instead of requiring multiple visits. For the government, it provided a predictable funding envelope. I appreciate this will come as a surprise to a couple of the frequent critics of my articles (in the comments), who have long implied that I was critical of Health Minister “Unilateral Eric” Hoskins because I was allegedly supporting the FFS model, but I actually have been in a capitated model since 2004.

UHN President and CEO Bob Bell

Drs. Bob Bell (left) and Eric Hoskins

Did PCR work? In 2001, the population of Ontario was 11.4 million, and almost 3 million people didn’t have a family doctor. In 2016, the population of Ontario was 13.9 million, and only 800,000 did not have a family doctor. So over 4.5 MILLION people got a family doctor.

Then along came the hapless “Unilateral Eric”, and his widely disliked sidekick, Deputy Minister Bob Bell. “Unilateral Eric” likes to claim that he himself is family doctor. The reality is that he has NEVER provided the cradle to grave care that comprehensive family doctors in Ontario do on an ongoing basis. He does work a day a month at a walk in clinic, and I understand he donates that income to charity – which is good of him, but it’s hardly the same as what comprehensive family doctors do. 

Bob Bell for his part, likes to boast about how he used to be a family doctor back in the 1970s, but he seems to be unable to grasp that family medicine might have evolved since then.

Acting with the same level of competence as Tweedle Dee and Tweedle Dum, the infelicitous duo of Hoskins and Bell unilaterally cut the number of family physicians who could apply to capitated funding models. Again, this is likely a surprise to a couple of the critics of my columns, who have long been demanding that physicians go on salary. Surprise, it was Hoskins and Bell who unilaterally stopped the salary style models, not the OMA. They also unilaterally cut some of the performance bonuses (for things like diabetic care, medical education and so on).

The result was clearly predictable to anyone who understands Family Medicine in the 2010s. Over the past three years newer graduates from Family Medicine programs are avoiding comprehensive care. Many of my trainees are choosing to work solely in areas like emergency, anaesthesia, sports medicine or others. And while there is a need for doctors in all fields, the reality is that it’s comprehensive Family Medicine that leads to health system stability. 

It’s comprehensive Family Medicine that reduces hospitalizations. It’s comprehensive Family Medicine that when supported properly, reduces costs of health care.

In response to this, the dolorous duo of Hoskins and Bell unleashed something called the New Graduate Entry Program (NGEP) to provide new family medicine graduates with what they claimed was a capitated funding model. Alas they attached so many conditions including a morass of bureaucratic oversight that I understand only two new graduates have taken them up on this offer.

Hoskins and Bell have left a legacy of a crumbling health care system with their arroganceand unilateral cuts. 

However, they still have the ability, and opportunity to begin to correct one of their most egregious mistakes. A new crop of Family Medicine Residents will graduate on July 1. Hoskins and Bell can unilaterally reverse the cuts to the capitated models and performance bonuses. No one from the OMA will complain.

It’s time for them to recognize the important role of comprehensive Family Physicians, and support that with actions, not just words.

Will Pharmacy Prescribing Improve Health Care?

Pharmacists do a great job as part of a health care team. In hospital and nursing homes, I get expert guidance on dosages of potentially dangerous medications. I am also fortunate to have community pharmacists on a secure electronic messaging platform to discuss issues around medication complications/interactions/dosages and so on for my patients.

But, will it improve health care to let them treat minor conditions?

I expressed my displeasure on Twitter about the recent move to allow pharmacists to treat certain minor ailments:

A few pharmacists were not amused. It was pointed out to me that Ontario is one of the last provinces to allow this, and that it has “worked well” in other provinces.

But what exactly is the definition of “working well”? Politicians love it, mostly because it allows them to say “see we are taking steps to make your life easier.” Patients love it because they can say, “Jee, I think I have a bladder infection, now I can just get the antibiotic when I want.” Of course patient satisfaction will be high.

Unfortunately, as I wrote about a few years ago in the Huffington Post, patient satisfaction does NOT correlate with good health care or outcomes. As counter intuitive as it may seem, higher patient satisfaction scores correlate with a 9% higher cost per patient AND a 12 percent higher hospital re admission rate. Patient satisfaction should not be used as a metric to determine any health care policy.

On Twitter, Nathan McCormick suggested that pharmacists have a lot to offer and linked to an article from New Brunswick on how it’s worked well there. Unfortunately (and I stand to be corrected) the article suggests the diagnosis of urinary tract infections was made without a urine culture, or even a urine dipstick test (which is less accurate but still something). So there’s no way to sort out how many people had a true bladder infection, or simply “felt” like they did, which happens. The article also puts a strong focus on patient satisfaction and convenience, which as mentioned above, is not the same as good health care.

Nardine Nakhla asked me to familiarize myself with an article she wrote about how Ontario developed the process. There’s a lot to like in what’s written there:

  • A recognition of overprescription of antibiotics as a world wide problem
  • a focus on ethical standards based behaviour by pharmacists
  • A minimum amount of training for pharmacists before treatment minor ailments
  • The requirement for pharmacists to contact the family doctor or nurse practitioner when treating a minor ailment

Once again this doesn’t really reflect true health care outcomes. It also references the aforementioned New Brunswick article and specifically stated there was high patient satisfaction there.

Let’s look at just one area of concern, antibiotic usage.  Global overprescription of antibiotics is a world wide concern.  It leads to increasing antibiotic resistance and the formation of new, drug resistant bacteria.  A look at Canadian data shows that there is intra provincial variation in the number of antibiotic prescriptions.  Newfoundland, where pharmacists have been treating minor ailments for years, has the highest rate of antibiotic prescriptions. British Columbia, where pharmacists are expecting an expansion of their scope this spring, had the lowest.  

From CMAJOpen: Interprovincial variation in antibiotic use in Canada, 2019: a retrospective cross-sectional study

World wide , of the ten countries with the most antibiotic use, Cyprus, Romania, and Greece allow them to be purchased directly from pharmacies. (I stuck to EU countries with more modern health systems for examples).

Kristen Watt wrote a piece in the medical post criticizing physicians for complaining about these new powers and asked me on Twitter to provide evidence from other locations.  She stated that Ontario was “15 years behind the trailblazing Alberta”. And yet the data in the CMAJ article above shows that Alberta has a higher rate of antibiotic prescriptions per capita.

One area I do agree with her is when she wrote:

“the government roll-out video, shot in a noticeable big box pharmacy, didn’t help us”

That big box is Shoppers Drug Mart, and their CEO Jeff Leger is seen promoting this change on the video.   Shoppers Drug Mart recently invested $75 million in Maple, a virtual care company.  Maple’s home page still shows the following:

Screenshot from Maple as of Jan 12, 2023

Gee, if you think you have a sore throat, you can just call a company (that Shoppers invested in), and get an antibiotic without a throat swab (who cares if it’s really strep) and lo and behold, there just happens to be Shoppers nearby that will deliver it to you. Yes, I know patients can request the pharmacy of their choice, but….

Look – there are other aspects of this process that need review.  Accurate diagnosis of a rash for example (several of the new pharmacist powers are for skin ailments). Or communication with the patients family physician about the treatments given.  Probably more.

I WANT pharmacists to help.  I really truly am grateful that so many are willing to step up in a time where our health care system is collapsing faster every day. But I want pharmacists to help in ways that support good health care outcomes.

 Might I offer three suggestions for how pharmacists can do that:

  1. As a group, they can petition Shoppers Drug Mart to put pressure on Maple to change the example on their website.  It’s great marketing (focusing on convenience) but terrible health care.
  2. Get involved with Choosing Wisely, Canada’s leading group looking at all ways to pick the right health care treatments.  There doesn’t appear to be a pharmacist in looking at their leaders.  I think pharmacists could provide extremely valuable information on not just anti-biotic stewardship, but also overall medication management (eg. reducing pill burden in the elderly)
  3. Strongly lobby the government for a unified integrated electronic health system that will allow them secure communication with physicians and access to limited health care data (eg creatinine clearance).  We’ve got this in my neck of the woods, and it’s a huge benefit to physicians, pharmacists and most importantly patients.

In order to save what’s left of our health care system (if that’s even possible now) we need to focus on health care outcomes, and ensuring proper an appropriate care. Doing the three things I listed above would be a big help in that direction.

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

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

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

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

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

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

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

Drs. Gigi Osler, Katharine Smart and Alika Lafontaine

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

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

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

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

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

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

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

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

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

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

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

It’s Time to Open Up Nursing Home Capacity

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Corporatization of Medicine Continues Unabated

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

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

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

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

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

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

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

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

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

Screen shot as of Dec 6, 2021

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

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

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

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

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