Patient Accountability

The Ottawa Citizen published my letter on patient accountability. This is one very important aspect of the tentative Physician Services Agreement, that the government finally acknowledges a need for patients to take responsibility for their own healthcare.

Here is the text of the letter:

Thank you to Mr. Reevely for interviewing Dr. Walley and reporting so reasonably on the tentative Physician Services Agreement.

 I do want to take issue with Mr. Reevely’s characterization of “patient accountability” as “code for giving people reasons to go to the doctor less”. To me and my colleagues, this means that my patients will be asked to take some responsibility for their health care and its cost. It means they will ensure that their health card is up to date, that they will go to their own doctor’s after hours clinic and not a walk-in clinic, that they will honour their specialist appointments. My physician colleagues and I believe that patients should realize the role of unnecessary tests and procedures in driving costs in the system and work with their doctors to limit these.  Most of my patients understand this. Since the sixteen year olds who are my patients understand these concerns, I believe everyone will. 

Including patients as accountable partners in health care is very important for the sustainability of the health system.

 

 

Which Doctor Do You Want?

Last Saturday, May 2, 2015, Dr. Michael Toth was installed as the 134th President of the Ontario Medical Association (OMA). Mike is a comprehensive Family Physician from Aylmer, Ontario. Aylmer is a town of 7500 in Southwestern Ontario. He told the guests at his Installation Gala that his patients range in age from newborns to over 100 years old.

I got to know Mike as a Board member in 2009, just after his election as Physician Services Committee CoChair. Within a month of his election he resigned because one of the physicians at the Nursing Home where he is Medical Director could no longer work there and Mike was needed in Aylmer to look after his patients. That’s the kind of doctor and person that he is. To me, he was one of the most powerful people on the OMA Board, but his patients came first. His lesson stays with me and so I juggle my OMA responsibilities so that my roles as a wife, mother and doctor are not compromised. Just like Mike, or as much like Mike as I can be.

Consider now a second doctor, the Minister of Health and Long Term Care, Dr. Eric Hoskins. After completing medical school and residency, Dr. Hoskins worked as a humanitarian and a doctor in war-torn regions around the world. With his wife, Dr. Samantha Nutt, he founded War Child Canada, which seeks to help children in regions around the world affected by war. His work has influenced policy and has been far-reaching. He is an Officer of the Order of Canada. Now a Member of Provincial Parliament for St. Paul’s, a riding just outside Downtown Toronto, Dr. Hoskins must wrestle with the issues of health care at home in Ontario.

As a citizen and a doctor, I hope that Dr. Toth and Dr. Hoskins will have a productive relationship. The OMA and the Government of Ontario are currently disagreeing about how to manage physician services, but that shouldn’t stop the two doctors most visibly associated with those resources from being respectful and courteous with each other. Dare I say collegial? However, Minister Hoskins was noticeably absent from Dr. Toth’s Installation.

A lot of Past Presidents hang out at Presidential Installations and I was told that Minister Hoskins’ absence was unprecedented. I asked all the people who might know and no one could tell me the reason for the Minister’s absence. No Past President could ever remember the last time a Minster of Health did not attend the OMA President’s installation. In 2012, two days before the Government imposed fee cuts on doctors, Minister Deb Matthews took the stage at Dr. Doug Weir’s Installation and warmly wished him well.

The relationship between the Ontario Medical Association and the Ministry of Health and Long Term Care is broken for the second time in three years. “Our situation cries out for common sense,” Dr. Toth said in his address to OMA Council the day after his Installation. Mike Toth understands common sense. He also understands common courtesy. I was born in one small town and grew up in another. Believe me, if you don’t have common sense and common courtesy, you won’t manage with the neighbours, let alone your patients, who may represent one fifth of everyone in town.

I hope Minister Hoskins let Dr. Toth know personally why he couldn’t attend his Installation. Dr. Toth would understand as much as anyone if the Minister had other family or professional commitments. He would not have taken it personally that he was one of the only OMA Presidents whose installation was not attended by the Minister of Health – he’s not like that.

But this small town girl is still taken aback. I was born in an English-speaking town and grew up in a French-speaking town. In both official languages, I learned that common courtesy and common sense were as necessary as food and uncommon kindness and genuine respect were the currency that bought you a special place in the world.

I suspect Mike Toth is more forgiving of Minister Hoskins than I am. Once again, I will learn from him and remember that it’s absolutely necessary to curb my tongue and get on with the work at hand. But first, I’m going to say that my money is on the small town doctor being the person who can bring some common sense back to healthcare in Ontario.

It’s possible that living in the big city of Ottawa has addled my brain and loosened my tongue.

Physician Fatigue and “On Call”

“On Call” and Physician Fatigue

In the past four days, I have been on call for two sixteen-hour shifts, although I worked from Tuesday morning at 8 a.m. until Wednesday at 9 p.m. This is well over the recommended sixteen hours various reports are recommending for physicians. I have recently been pondering the Royal College’s consideration of resident work hours and these four days with my own duty hours being extended have focused my mind on their work. This is the link for the study: http://www.residentdutyhours.ca/documents/fatigue_risk_and_excellence.pdf

During the time when I am working, and especially when I am on call, I follow the tenets of this small text called: Why were the saints saints? Here is the text:

Why were the saints saints?

Because they were

cheerful when it was

difficult to be cheerful,

patient when it was

difficult to be patient;

and because they pushed

 on when they wanted to

stand still, and kept silent

when they wanted to

talk, and were agreeable

when they wanted to be

disagreeable.

That was all. It was quite

Simple and always will be.

This text was quoted in the Anglican Journal this past week, in honour of All Saints’ Day, which was yesterday. The author is unknown, but hopefully a saint. I’d like to know he or she walked the walk and not just talked the talk.

I am not going to pretend that I am always able to follow these tenets at work – especially since there are a few people reading this who might comment to the contrary – but they are my goals and, when I follow them, they smooth the way, especially in the evening and night when it is so difficult to work. They help me deal with tired parents, intoxicated adolescents and Emergency Room staff who are under even more pressure than me (and who seem to eat a lot of Hallowe’en candy). They also help me to focus the following day, which I should have booked lightly, but didn’t because, really, it does seem a better option to begin a new assessment fatigued than let someone wait another several weeks for treatment. These are choices that every doctor reading this will understand, as well as anyone who has been waiting to see a doctor for themselves or their mother, or child, or partner. I do this not because I am indispensible but because I can make things easier and this is an important value for me and for many physicians. Doing more of your own work than may be advisable for personal health is the one thing that physicians do all the time that improves the efficiency of the system. Since I believe that my own role as psychiatrist in an Outpatient Department is to be an acolyte for family doctors and primary therapists, as long as I can facilitate youth getting care, I can often complete an assessment without being at the top of my game. I can always recognize when someone is VERY SICK. Also, I assure you, and so could many other physicians, that nothing gets you to the top of your game faster than the symptoms and signs that someone is VERY SICK and needs something done RIGHT NOW.

I do not know how to add these “insights”, which I believe every doctor knows, to the current debate on physician fatigue. All physicians want balance in their lives, but no physician will accept balance at the cost of doing a mediocre job. The system still depends on many of us working more than sixteen hour shifts from time to time. Imagine: your child’s school calls to say she has suddenly developed a rash to go with the cold you thought she was starting. Do you want your family doctor to extend their day, even if they have been working since yesterday morning, or send you off to the Emergency Room? It’s likely that your family doctor, like mine, will see your child, because it’s more efficient and easier on everyone, as well as the system. It’s likely that this is what you’d prefer also.

What has physician fatigue got to do with the saints and the text I copied out? For me, when I can no longer follow those “simple” rules, it’s time for me to leave work. Maybe leaving for half an hour will do and maybe I will need to leave for longer.  I do ask myself: Am I still patient? Am I still cheerful? It is a problem that the guidelines for knowing when you’ve been at work too long can be found by extrapolating from a text about saints. This is especially true because I think this is still what we expect of health care professionals, and especially doctors. The child psychoanalyst Winnicott considered what was a “good enough mother” and someone needs to consider what is a “good enough doctor”. I am not sure this “good enough doctor” is going to be described scientifically and a problem in medicine right now is that we believe that all of our evidence must come from scientifically proven facts. The art of being a physician still involves night toil and the problems that do not resolve by 6 p.m. Sometimes the answers about what to do will not come from academic journals but from older texts on how to live your life. Medicine, as Osler said, is “a way of life”.

Amen.