#sundaysnippet – justanoldcountrydoctor

Sunday Snippets – November 17, 2024

Another in a weekly series of brief snippets of health care stories that bemused, intrigued and otherwise beguiled me over the past week along with my random thoughts on the matter.

Item: New reports show that marijuana use is linked to thinning of brains in adolescents.

My thoughts: It’s not just adolescents. And it’s not just brains. I’ve seen a marked rise in people with significant mood issues ever since marijuana was legalized. There has also been a significant rise in people with stomach/bowel issues in my practice that all other tests turn up negative for. Patients with these issues are invariably marijuana users and the blunt reality is they won’t get better until they stop. I continue to be in favour of decriminalizing marijuana and other illicit street drugs if and only if we do it the way Portugal did it and not the haphazard way it is being done in Canada. But we really need to re-think the full on legalization of it.

Item: A survey in Medscape showed that there were two factors critical to reducing family medicine burnout. First would be to reduce the Electronic Health Record burden, particularly the number of times family physicians have to chart from home. Second would be to build stronger physician/nurse teams. Crucially, the teams need to be led by the family physician and NOT a bureaucrat or some other team member.

My thoughts: I hope this finally gets the Canadian Medical Association (which despite over $2 billion dollars in their bank account is amazingly growing increasingly irrelevant to front line physicians) to SHUT UP ABOUT SICK NOTES ALREADY. That’s not going to solve burnout (even though I like every other doctor hate doing them). To paraphrase a political slogan – “It’s the Electronic Health Record, stupid.” My second thought is that I remain extremely concerned that while I do feel Dr. Jane Philpott is well intentioned in her new role (to lead a primary care action team) – the bureaucrats at Ontario Health will sabotage her. They will see “teams help”, then create teams that have the assistant to the secretary to the aide to deputy minister’s attache for the Primary Care Secretariat’s deputy vice president run them. That will be a disaster. Teams need to be led by family physicians. Full stop.

Dr. Jane Philpott, head of the new “Primary Care Action Team” designed to give everyone access to primary care in 5 years.

Item(s): The family physician crisis in Ontario continues to worsen. Tillsonburg lost four family physicians. Wallaceburg is launching a large physician recruitment program to deal with their shortage. Brantford is taking a more hands on role to get more family physicians. Brockville is hiring a consulting firm that employs former health Minister George Smitherman to help tackle their shortage.

My thoughts: It’s sad that we are in a seeming “Hunger Games” of one community fighting another for the precious resource that is a family doctor. If only someone had warned people a crisis was coming. Oh, right.

Dr. Nadia Alam, who, like others, warned that the crisis in family medicine (and health in care in general) was coming ten years ago, and was ignored by governments.

Item: Premier Ford promises to correct the mistakes at Ontario Health at Home that led to a large amount of suffering for patients. He also stated that the people who “messed this up” will be “held accountable”.

My thoughts: I’ll believe it when I see it. When I wrote about mismanaged bureaucracy in health care (back in 2015!) I pointed out that no decision seems to get made by bureaucrats without continuously “circling back” to one committee or another. The reason I’ve discovered, is because this way, no individual gets blamed for (the very many) bad decisions made in health care. I’ve yet to see a health care bureaucrat fired – and I’ve met many who deserved to be. I really hope that the comments by Premier Ford signal a return to the old Doug Ford who promised to end the “gravy train” and famously said:

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

Doug Ford, Premier of Ontario for almost 7 years, and the gravy train in Ontario Heath continues unabated

Item: Male doctors are working less hours in a week than they used to. They are still working more than the average Canadian worker, but there has been an unmistakable decrease in how many hours they work

My thoughts: Finally! Proof that men are getting smarter! There’s more to life than work, and good for the younger docs – all of them – for seeking balance in their lives.

Item: A young Ontario mother died of cholangiocarcinoma (cancer of the gall bladder), after encountering multiple road blocks getting a new treatment (Pemigatnib) approved for her.

My thoughts: This story is absolutely infuriating and encapsulates what is wrong with our health care system. Look, there is no guarantee that she would have survived if she had gotten the treatment (it’s an awful cancer she had). BUT – look at all the regulatory agencies involved in getting the drug approved. Health Canada approved the drug in 2021. But the Canadian Agency for Drugs and Technology in Health said the evidence wasn’t clear. (So why then did Health Canada approve it?). Furthermore there are multiple provincial drug agencies involved, which means she could have gotten it had she been a resident of Quebec, but not Ontario (two tier medicine anyone?). It’s the bureaucracy and double speak from having too many agencies involved that angers me greatly. A wholesale streamlining of the process for medication approvals is desperately needed.

That’s all for this week. Back next week (probably) with more.

Sunday Snippets – November 3, 2024

Another in a weekly series of brief snippets of health care stories that bemused, intrigued and otherwise beguiled me over the past week along with my random thoughts on the matter.

Item: AI is now inventing things no one ever said. It turns out that AI can “hallucinate” (no really, that’s what they are calling it). Apparently the AI invents commentary that includes things like racial comments/violent rhetoric (!) and even medical mis- diagnoses.

My thoughts: My group is actually looking at AI to help with our Admin burden. While the technology shows promise – this is a useful reminder that we should all read what software generates before logging off. You will probably still save some time, just not as much as hoped.

Item: A new lung cancer vaccine that uses mRNA technology is entering trials. Somewhat ironically, this is what mRNA technology was being studied before the COVID pandemic, and its use for the COVID vaccines. The technology shows great promise to greatly reduce the side effects of cancer treatment, and provide more targeted therapy.

My thoughts: The “vaccine” term is probably going to need refining, because it’s not really preventing lung cancer (which is what most people associate with the term vaccine). Additionally, social media is still awash in mis-information about mRNA technology. So probably better to avoid that term. But at the end of the day I would agree what we are really in a remarkable time for cancer therapy with so many new treatments available. (Still better not to get cancer of course – so if you do smoke – quit!).

Item: Dr. Elaine Ma, a physician who went over and above the call of duty to organize mass vaccination clinics in the Kingston area at the height of the Covid Pandemic is asked to pay back the billings generated during those clinics. (Note I did not say income – Dr. Ma would have used a good portion of those billings to pay staff, supplies and other overheads).

My thoughts: I’ve been (frequently) told I’m too hard on bureaucrats in health care. That I come across as somewhat insulting and “un-presidential” when I complain about them. And every time I think to myself “I really need to take a deep breath and be hard on the problem, not the people” – along comes yet another example of rigid bureaucratic thinking and frankly bureaucratic stupidity that I wind up reverting to my old habits. I will say this, the residents of the Kingston area are a whole lot better off because of Dr. Ma , and the sooner the OHIP bureaucrats get this, the better. As for the OMA’s silence on the matter, it’s pretty disappointing.

Addendum: after writing this blog the OMA has confirmed that they have been helping behind the scenes. I’m glad to hear that they have been helping Dr. Ma, but I would state for the sake of their members that they need to be SEEN to be helping….

OMA Board Chair Dr. Cathy Faulds, who has been silent on Dr. Ma’s abhorrent treatment

Item: The Registered Nurses Association of Ontario blasted the government for not embracing nurses as a central to solving the primary care crisis.

My thoughts: I admire the RNAO for advocating for their members (no really, that’s kind of what a member organization is supposed to do). They’re wrong of course. Using Nurse Practitioners to replace physicians (as opposed to complementing them) will only massively drive up the cost of health care and worsen outcomes. But unlike certain organizations- see above – the RNAO stands up for its members.

Item: Walking pneumonia rates in the United States – and probably Canada – are spiking, particularly in young children.

My thoughts: It’s always awful to see children sick, and as clinicians we should be on the look out for this. BUT – thankfully the vast majority of cases appear to be mild, and if treated appropriately people are recovering. They may have a persistent cough for several weeks – but they are getting better.

Item: Collingwood’s newest physician says that the profession is endangered until the province ante’s up better pay. Disclosure – Dr. Ladda has joined my Family Health Organization and I feel we are lucky to have him.

My thoughts: Read my full blog tomorrow – written by a guest blogger so at least it will be coherent.

Item: A columnist in the Ottawa Citizen basically says that Premier Ford is outsourcing the family medicine problem.

My thoughts: A good friend of mine says it much, much better than I could. “We need the political leadership to step beyond name calling and giving token titles to people to win an election. If you want this province to thrive, rebuild and lead Canada again, it requires more than what we have seen for 20 years from ALL political parties .”

That’s it for this week’s Sunday Snippets. As mentioned above, watch out for a really superb guest blog tomorrow on how to fix family medicine.

Sunday Snippets – Oct. 27, 2024

I was away last week but I’m back with another in a weekly series of brief snippets of health care stories that bemused, intrigued and otherwise beguiled me over the past week along with my random thoughts on the matter.

Item: There was significant growth in the number of physicians in Alberta in the third quarter.

My Thoughts: Alberta is kind of a funny province. There are some very strange goings on with their health care policy. But it can’t be denied that despite all of that, if you provide incentives to attract younger physicians it will help. Having said that, it can all be easily undone if they don’t get on with it and implement the compensation for family physicians they promised, and for some reason appears to be delayed.

Item: The province of Nova Scotia has launched a physicians retirement fund initiative, helping physicians to retire well.

My Thoughts: What’s that you say? You mean ensuring that physicians have peace of mind about their retirement might actually help recruit (gasp!) and even retain (double gasp!!) physicians? Who would have thunk it?? In all seriousness, given the way the Federal Liberal government of our effete Prime Minister really screwed physicians with the recent tax law changes – this is a necessary move and I hope will get copied by all provinces. It really will help improve morale and reduce some of the burnout.

Item: John Richards and Tingting Zhang, from the CD Howe Institute wrote an op-ed in the Financial Post encouraging more use of nurse practitioners since they can “do almost everything an MD can”.

My Thoughts: El Toro Poo Poo. (This is a PG rated blog so that’s all I could get away with). I work with Nurse Practitioners and I have seen them help patients and I firmly believe they have a role in health care. But that role is not to replace physicians. The studies that show they can “do almost everything” are done based on what scope of practice suggests they can do. The blunt reality is nurse practitioners drive up costs and worsen care if used in settings as these characters suggest. The studies that show that NPs are cheaper ONLY look at the actual income an NP gets and compare it to a physicians income, as opposed to looking at the work that is actually done/number of patients seen/and number of tests ordered. The FP article isn’t even fit to be used for toilet paper.

Item: The crisis in Home Care supplies, first reported by Avis Favaro on X (formerly Twitter) continues. Home care nurses are reporting heartbreaking stories of patients buying their own supplies on Amazon since home care couldn’t provide them. Dr. Drew Moore and Dr. Hal Berman should be lauded for going public with their concerns. (I’ve met both of them and they are both mensches).

My Thoughts: I’m old. I’ve seen a lot of government screw ups in my time, especially in health care. But I have yet to see bureaucrats who screw up be truly held accountable and fired. Ever. They just get shuffled off to some other department. It it too much to ask that if someone makes a mistake at their job (and this is a BIG one) they get held accountable?

Item: Quebec is attacking family doctors for some reason. First they suggested they would link people to non-family physicians for care and even remove patients who were “healthy” from their own family physicians. Then they presented erroneous data suggesting that family doctors basically don’t work hard enough.

My Thoughts: There are 9 other provinces and 3 territories that would love to have these doctors.

Item: Penn State Medical Residents unionized, went on strike and got significant benefits (despite being driven off the hospital grounds by hospital security!)

My thoughts: Unionization of physicians is going to happen eventually. Whether through the long gestating Charter Challenge (yes my Ontario peeps – it is still working its way through the courts) or some other mechanism. The younger physicians clearly seem to want this model of representation and at some point in the not too distance future, physicians will be unionized.

Item: The Ontario government announced plans to effectively bar foreign students from attending medical school in Ontario.

My thoughts: My thanks to Am640 News for interviewing me on the topic, and my thoughts on this can be heard below. (This short version – this is populist rhetoric that will do nothing to help with the health care crisis):

Sunday Snippets – Oct 13, 2024

Another in a weekly series of brief snippets of health care stories that bemused, intrigued and otherwise beguiled me over the past week along with my random thoughts on the matter.

Item(s): CBC new is reporting that with more food insecurity, physicians are being urged to be on the lookout for scurvy (!!). Similarly, Canada Health Network reports that ferritin (iron) levels are being re-visited to help better identify those with iron deficiency. More concerning studies on the link between erythritol and heart attacks. While there have been no randomized control trials, the number of studies correlating having too much of this very common artificial sweetener to blood clotting disorders (heart attacks, pulmonary emboli, strokes) is very concerning. And finally Medscape published a study showing eating Ultra Processed Foods leads to weight gain.

My thoughts: I’ve long maintained the North American diet is garbage. It’s embarrassing that first world countries like Canada and the US put so much crap in our food. The US for example has over 10,000 chemicals that it allows in its food. Compare this to Europe where they are much more stringent in their food standards – and of course, Europeans are slimmer. A good first step would be for Canada and the United States to immediately adopt European food regulations. The big multinational food companies already have to make products meeting European Union standards anyway. Just have them make all their products that way.

For more watch this (hilarious but salty) video of Comedian Leslie Jones on her trip to Europe, where it turns out a peach actually tastes like, you know, a peach.

Item: Doctors Manitoba issued a joint task force report on reducing admin burden for family physicians. The report not only include steps that need to be taken, but clearly lists the progress on each step.

My thoughts: I should move to Manitoba. The amount of progress they’ve made is impressive. Compare that to the utter and complete joke that is in Ontario. For the un-initiated: The Ontario Government and Ontario Medical Association formed a task force to reduce paperwork for family medicine. The result of said joint task force (after over a year of work)? An announcement made on Jan 29 of this year that hearing aid forms (which take about 10 seconds to fill out) no longer need to be signed by family doctors. With no announcement of any further progress. Worse it turns out that the College of Audiologists refused to let “hearing aid specialists” sign the hearing aid forms, it had to be only Audiologists. But most hearing aid clinics are run by hearing aid specialists.

I got four forms to sign last week….

Item: New Brunswick PC party leader Blaine Higgs insists that “business acumen” is needed to run health care and that efficiencies can be found in the system.

My thoughts: Yes, yes and more yes! I don’t know what the New Brunswick health care budget is, but we spend over $80 billion dollars on health care in Ontario. That’s more than enough. So much is wasted on bureaucratic silos and inefficient methods of care that it’s embarrassing. A hard business approach is needed.

Item: A study conducted by OntarioMD showed that there was a 70% reduction in time spent on patient encounter documentation when using an AI scribe (in this case the study was limited to Well Health’s software).

My thoughts: The AI scribe most commonly used in my neck of the woods (I don’t use one) is very very poorly received. It’s clunky, cumbersome and requires a lot of clicks. Can AI help? Of course it can and hopefully the Well Health one (which I have not seen) is better. But the software needs strong physician input to develop to ensure user friendliness – or it will wind up like EPIC – one of the main hospital IT systems, which, well, is best described by none other than Dr. Glaucomflecken himself:

Item: Ontario Medical Association President Dr. Dominic Novak spoke to the Standing Committee on Finance and Economic Affairs at Queen’s Park. While he talked about the admin burden driving physicians out of running a comprehensive care family practice, what people seemed to be talking about was the focus on eliminating sick notes.

My thoughts: I’m glad Dr. Novak is speaking about the admin burden. But seriously, can we move the focus off the sick notes? They take me one minute to do, and I get $25 for them. The real admin burden that is driving people out of family medicine is the constant reviewing of lab data, downloading reports, re-categorizing mislabelled reports (my personal feeling is EPIC is really a problem for this) and so on. I don’t get any money for doing that. Keep your eye on the big picture.

Item: Bill 121 the “Improving Dementia Care in Ontario Act” had more readings at various committees in provincial parliament. The bill seeks to help the estimated 315,000 people in Ontario with dementia right now (a number that is expected to triple by 2050).

My thoughts: It’s overall a good Bill. We certainly need to support and care for our elderly. The true measure of the strength of a society is reflected in how well they care for the weakest among them. I just hope that we look at some of the novel models of elder care in Europe as well, to give our seniors the compassionate, dignified care they deserve.

Item: Health Journalist Avis Favaro published on X (formerly Twitter) that there is a dire shortage of supplies in Home Care. Some sort of issue with the new supplier for the Home Care system. She mentions that the shortage is being described as a “crisis” internally. Without the supplies (syringes, needles) patients are unable to get needed medications and treatment at home.

A dire shortage of medical supplies is being reported by front line home care #nurses in Ontario. The new supplier for @OH_atHome isn't able to make timely deliveries of key things like syringes, catheters and wound care supplies. I am hearing it is described internally as a…
— Avis Favaro (@Avis_Favaro) October 11, 2024

My thoughts: I have not seen this personally myself. But I’ve heard some horror stories from my colleagues. I hope this gets resolved ASAP.

That’s it for this week. I’m away next week and will return with Sunday Snippets in two weeks.

Sunday Snippets – October 6, 2024

Another in a weekly series of brief snippets of health care stories that bemused, intrigued and otherwise beguiled me over the past week along with my random thoughts on the matter.

Item: Ontario nurses are leaving the profession in droves. This article from the Seeker states: “Ontario ranked third, with 35.1 young nurses leaving for every 100 entering in 2022. This is 83 per cent higher than in 2013.” The overall numbers for Canada aren’t pretty either, with an expected shortage of over 115,000 nurses by 2030.

My thoughts: Who can blame them? Most of the nurses that I work with are really excellent at their jobs and try their best. But, much like with family physicians, they are now relegated to data entry clerks for EMRs that require a PhD in software programming to understand, bear the brunt of patients frustrations and suffer high rates of workplace violence. Yet more reason to implement drastic health care reform now.

Item: The Ontario Federation of Labour met in Sudbury, and have come out with some pretty strong statements about the state of health care in the north. The article is damning with condemnations just how broken our health care system is in Ontario.

My thoughts: I get that Sudbury is a union town and not really a Conservative stronghold, so there is bound to be criticism of the Conservative government there. I also get all the talk about potential early elections and strong results in by-elections pointing to another victory for Ford. But if meaningful steps to fix health care aren’t taken now, this issue is going to haunt the Conservatives in the next election (whenever that is).

Item: The National Post ran a harrowing account about Christine Tizzard and how she paid almost $100,000 US for out of country care when our health system failed her. CBC reported on a woman who likely will have to wait three years to have her surgery.

My thoughts: When I wrote that if I were to get a serious illness, I would go to Turkiye for my health care needs, I was met with blowback. Some of that was because I consult for a medical tourism firm (I did disclose that in the blog and am quite open about it). Some of that was because I seemed to be taking a somewhat “un-Canadian” stance on health care. But the more of these stories that come out, the more I’m convinced I’ve made the right decision.

Item: Dr. Michelle Cohen writes about the letters that the Ontario Ministry of Health sent to (by my rough count) several hundred family physicians last week. They were in 75 group practices called Family Health Organizations (FHOs). While it’s true I wrote about this last week as well, she did a much better job and I encourage you to read her blog.

My thoughts: She’s a great writer.

Item: The Annals of Internal Medicine published an article showing significant benefits to intermittent fasting (or time restricted eating) for health.

My thoughts: I’m a big fan of intermittent fasting. I think it’s the simplest and most straightforward lifestyle change to make and has huge benefits.

Item: A new Angus Reid poll suggests the current Conservative government increased its potential votes share despite it getting terrible ratings on government performance. In particular, 80% of those polled thought they were doing a terrible job on health care. The numbers on housing and affordable living were even worse.

My thoughts: As mentioned above, just because it looks like another Conservative win, doesn’t mean it will be. There is an awful lot of dissatisfaction out there. Several months or a year are an eternity in politics. I wouldn’t be so sure of the results of the next election without meaningful improvement in those numbers.

Item: New Covid-19 vaccines are available at pharmacies. But there is rather a lot of concern about “vaccine fatigue” and also around the fact that messaging around these vaccines has been poor.

My thoughts: Get vaccinated. Get your flu shot as well. And if you are in a high risk group – get your RSV vaccine as well. The fact the messaging around vaccines has been poor will be little solace to you if you wind up with a bad preventable infection that hospitalizes you and leaves you with long term complications.

Item: The Toronto Star reports yet another nursing home decided to close, rather than go through the upgrade process to meet 2024 standards. North Park has 75 residents, all of whom will need a new place to stay. Additionally this comes while it is well known that the demand for nursing home beds will only increase (44,000 people on the wait list right now according to the article). The article pointed out that 25 Toronto area nursing homes have their licences set to expire in July 2025 and there is no guarantee these will be renewed.

My thoughts: The current government has pledge to build 30,000 new nursing home beds by 2028. Good for them. But I worry that with so many others closing this will not be enough. We need to start looking at alternatives for our seniors, such as various living at home programs so that they can be cared for with dignity and compassion. I also hope the new nursing homes will follow the “Butterfly Model” of care for the aged.

That’s it for this week. More snippets hopefully next Sunday.

Sunday Snippets – Sep 29, 2024

Gonna try something a little different. Over the years I’ve often found that there are a number of small stories that happen in a a week that are not worthy of a blog, but worth disseminating. So every Sunday (fingers crossed) I’ll try to collate (briefly) some stuff that happened in the past week in health care, along with my thoughts.

Item: Government of Manitoba announces a large number of health care workers (including 116 NET new physicians – a new record) have moved to the province in the past year.

My thoughts: It just goes to show you how a province and its residents benefit when government’s treat physicians fairly and come to a deal rather that dragging things out through an acrimonious arbitration processes. The second thought is it goes to show the political spin around health care will never end. It was the previous Conservative government of Heather Stefanason that signed the agreement with Doctors Manitoba that has bolstered their physicians population. New Democrat Premier Wab Kinew taking credit for this is somewhat laughable, but let’s face it, if the situation was reversed, the party in power would do the exact same thing.

Item: Private physician social media sites are complaining about some sort of change at the Pharmacy and Administrative level at Ontario Health around processing orders for palliative patients. It’s taking much longer for symptom relief kits, pain pumps, subcutaneous medications and the like to arrive. Hasn’t affected me or my patients yet, but apparently new process means that you have to have all your orders in place by 1:00 pm for them to get done on the same day, and stories are popping up in physicians facebook groups about patients suffering and nurses not having the tools to do their jobs.

My thoughts: It’s not a problem. I’ll just tell all my palliative patients that they are not allowed to de-compensate after 1:00 pm on weekdays and never on weekends. That’ll fix it.

Item: Yet another excellent op/ed written about how difficult it is to get a family doctor in Ontario and how you shouldn’t need a “golden ticket” to get one.

My thoughts: Honestly don’t know what it’s going to take for the government to take some action on this issue at this point. Or for the public to march on Queen’s Park daily.

Item: Vice-Chair of the Ontario Pharmacists Association terminates her agreement with PrescribeIT over a funding dispute. I gather there is some sort of transaction fee now for pharmacists.

My thoughts: There are, huge benefits to having a completely integrated digital health system. I’ve referenced countries like Turkiye and Estonia before about this. Reality is thatmost advanced countries have integrated electronic health care (except the United States). The government should fund this – the savings will far outweigh the costs, if done properly.

Item: Dr. David Price responds to the criticism of him being chosen as a keynote speaker by the College of Family Physicians of Canada for their Family Medicine Forum.

My thoughts: I found it odd that his response included internal Ministry NTF processes. My understanding is that stuff was supposed to be ultra secret. In particular he mentioned a proposal was coming well before presented and announced. He didn’t specifically mention numbers per se. But he also seemed to back off supporting the 3% increase (which he isn’t allowed to do under team rules) or at least suggest it wasn’t his idea. If he was on the OMAs NTF he probably would have been kicked off for saying this stuff, but I guess the government, as always, plays by different rules. And saying he would be happy to not give the Keynote was……..strange. Oh well, at least it gave the chance to do this (and yes you can re-post from here if you want):

I continue to encourage all family physicians to sign the petition asking the CFPC to remove Dr .Price as a keynote speaker by clicking on this link.

That’s it for this week’s Sunday Snippets. A blog on how the Ontario government continues to attack family physicians coming in the next day or two. See you (hopefully) for more snippets next Sunday.