Patient Accountability II

In January, I wrote a brief introductory essay on the reasons I feel patients must be included as full partners in health care, having not just the right to good care, but also responsibility for certain facets of the health care system.  There were so many comments and concerns raised by that introduction that I felt it was important to follow up with a bit more information to think about and clarification of why, in my view, patients need to be full partners in accountability.

One of the striking facts about the Canadian provincial health plans is that government documents and websites highlight patients’ rights and never mention patients’ responsibilities. I looked through the documents for each province and territory. Here are links from the British Columbia website and an Ontario government website for new immigrants as examples. I attempted to find a document for Ontario similar to the British Columbia Document, but this did not seem to exist, except for new Canadians. The document for new Canadians does list responsibilities but I was struck by the fact that the website also contains this phrase: “You are entitled to all of the patient rights that are described in Ontario laws, even if you do not follow these “responsibilities.”  The other document I have included is a Government of Canada comparative overview of patients’ bills of rights from around the world. Note once again that rights are noted without mentioning responsibilities.

Contrast this with the fact that other countries with a publicly funded system do list both patients’ rights and responsibilities. This is also true of many physician practice groups in Canada and hospitals. Both hospitals and physicians’ practices absorb the costs in their budgets if time or resources are not productive. In my hospital’s Youth Psychiatry program, missed appointments or late arrivals mean delays for another patient’s assessment or treatment. That’s why we have a rule that, if a patient misses more than two appointments without 24 hours’ notice, we close the file. Given that Ontario’s healthcare budget covers the cost of the therapy provided in the Youth Program, most patients and their families understand that missed appointments affect access to care and accept the rule.

The emphasis of patients’ rights, in the absence of a consideration of any responsibilities, makes physicians uneasy. It also makes many physicians, including me, feel as though the responsibility for stewardship of the system is not shared by patients.

All physicians have days when we feel as though every appointment consists of reviewing with patients that the tests they want are unnecessary and treatments they would like are proven to be ineffective. Physicians honestly want to follow best practices, and improve system efficiencies and these discussions with patients about necessity prove that. Physicians could have much less conflict in our days if we just agreed to order every blood test, consultation or x-ray that patients request. At the same time, every physician I know is very understanding when a person’s living conditions or financial situation make it impossible for them to follow the recommendations they’ve received for examinations or treatment.

One reader of my last Patient Accountability essay commented that defining patients’ responsibilities was a “slippery slope” to blaming patients for their health problems. My experience is that anything less than a full discussion of a patient’s history, examination and diagnosis, along with an outline of the best practices for further tests and treatment is a “slippery slope” to an old style of medicine in which the patient was expected to “do what the doctor ordered”. That kind of paternalism is no longer acceptable in medical practice. The standard of care today is to review the diagnosis and recommended tests and treatments thoroughly so that patients understand the options for further evaluation and treatment and consider with their doctor and other care providers what would best for them. Patients no longer want to be patronized by the doctors providing their care.

Canadians are aware that their much-celebrated health care system is not keeping up with demand and it would be a relief for most people to know that there was something they could do to preserve and improve their health care. We are all aware that many Canadians can no longer afford necessary medications, but we also realize as our national and provincial deficits increase that we cannot spend away the health care system.  Providing good care in the context of excellent information about best practices is what all doctors try to do. My experience with patients is that they want this information so that they can do whatever it takes to get well. How is that not taking responsibility? Why can governments in Canada not accept that this is the right thing to do?

Finale

In my last moments as Chair of the Ontario Medical Association Board, I thought of the five remarkable doctors, my former colleagues on the Executive Committee ,who have been my inspiration for the past six months. They embody the compassion, devotion and civility that epitomize physician leadership. I have learned so much from them.

Like my colleagues, despite having Council’s confidence to continue personally, I found the vote of nonconfidence in the Executive Committee in general to be extremely troubling.  As much as I want to assist in mending the divisions within the Ontario Medical Association, I believe that the best thing I can do is to assist as a Board member for a few more months.  The past six months have also taken a toll on those who care most about me and my clinical work so I feel it is important to attend to the interests of my family and my patients.

I am first and foremost a doctor and nothing is more satisfying to me than watching the life come back into a young person’s face as their depression lifts. I am inspired by the clinicians that I work with in my hospital and my community. The doctors and nurses, psychologists, social workers and other clinicians in my hospital keep me grounded in what is most important in medicine. They are amazing.

In ten years of medical politics, I have learned that I am not a politician. I can’t learn the lines or follow the cues. As too many people tell me, I cannot keep my facial expressions under control. If I have had any success, it is because I am persistent. It is because my efforts to be tolerant and gracious and kind have occasionally been successful. It is because, having always worked with youth, I have learned not to take my self too seriously.

The picture below is my favourite picture of me in OMA service. This was taken last November with Ontario’s medical student leaders. On the days when I have the most worries about where we are headed, I think about these doctors-in-training and I am reassured. If the work I have done for the Ontario Medical Student Bursary Fund and Physician Human Resources have had an impact for one young doctor, then my time at the OMA Board has been well spent and I leave with a light heart.

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(Photo credit: OMSBF)

Patient Accountability: Is it reasonable?

I am puzzled by Canadian federal and provincial governments’ collective reluctance to make patients partners in their own healthcare by expecting them to accept certain responsibilities for their own health and for the sustainability of the healthcare system. Why does it seem unreasonable to governments to ask citizens to meet a minimal set of expectations in relation to health care? All Canadians pay taxes, follow traffic laws and remember to get their passports renewed. Why would they not manage similar expectations in relation to their healthcare? Healthcare is thought to be a right by many Canadians – don’t we expect to have responsibilities related to rights? Why wouldn’t we be as accountable for our health care as we are for our taxes?

The issue of patient accountability is important for me as a physician. Whenever I see resistance by the government to patients accepting reasonable accountability, it feels as though the government is saying that the responsibility for the sustainability of the health care system mostly rests with frontline providers, especially physicians.

The Government of Ontario seems to like many aspects of Kaiser Permanente’s model for health care delivery so I thought I would see what Kaiser expects of patients registered in their programs, just to see how far-fetched my notions of patient accountability are. This is a link to the section of Kaiser Permanente’s website called Your Rights and Responsibilities. The section has a list, first of all, of rights. A quick read through this will show that these are the same expectations of any Ontarian of the Ontario Health Insurance Plan, although some of these include such statements as: “Receive emergency services when you, as a prudent layperson, acting reasonably, would have believed that an emergency medical condition existed.” The next portion is about patients’ responsibilities as a client of Kaiser Permanente. There are sixteen expectations in all, grouped under three broad categories: Promote your own good health; Know and understand your plan and benefits; Promote respect and safety for others. All are reasonable; all would be easily adaptable to the Ontario situation.

So what is the big deal? Unfortunately, Minister Hoskins has often said that health care is “free” – he did this last flu season, suggesting patients get their “free” flu shot at their nearest pharmacy. Leaving aside the fact that health care is not at all “free” from a financial perspective, it sounds as though governments believe that “free” should also mean “free from any inconvenience or expectation of the patient”. But we don’t say this for other government programs – try being free from the “voluntary” aspect of your income tax, or paying a parking ticket. You’ll soon learn that the government has ways of making you meet these expectations. When health care is the single largest budget item for a provincial government, why not expect the same attention to missed medical appointments, or seeing multiple doctors through walk-in clinics? It almost seems as though the government knows that this is one of those places where you can let someone else be the bad guy. You can let me be the one to say, “You missed two appointments with no notice and, as you were told at the outset, we will not continue to see you at the clinic if you miss appointments without letting us know.”

Now that Ontario’s ability to provide health care is being limited by the resources available to fund it, now that all other efficiencies in the system have been found, is it not time to turn to patients to ask them to contribute to the system? Is it not time to say, “There are some ways you could make the system more sustainable”? This is true in Ontario, but it’s also true in the rest of Canada as well.

The Ontario government is so desperate to find resources for health care that cuts to both physician and hospital services are continuing. However, it seems that legislators are not so desperate as to risk the anger of voters by asking patients to be accountable for those elements of health care that they control. I think that most citizens are committed enough to the health care system that they would welcome the chance to make it better. As baby boomers see how cutbacks are affecting health care, either through their own experience or that of family members, they are realizing that there is a role for them to play. It’s time to ask everyone to embrace accountability.

Ministers

I am getting pretty fed up with Health Ministers. Ontario’s Minister of Health and Long Term Care, Eric Hoskins, dumped a “deal” on the table for Ontario doctors at 8 a.m. last Wednesday morning. He was in a press conference by 9 a.m. letting the public know that he had offered Ontario doctors more money than he had in August 2016. Not mentioning that the doctors had rejected that August deal, the Minister also neglected to say that he had decided to pit groups of doctors against each other with his most recent offer. His latest “deal” seems to give family physicians an increase at the same time as it cuts the highest paid specialists.

The “increase” to family physicians is very questionable since the terms and conditions to which extra funding is tied are so stringent that doctors would take a loss in order to meet the Minister’s demands. The timing of the offer is also suspect. It follows hard upon the passage of Bill 41, the so-called Patients First Act, which seeks to address problems in Ontario’s health care system with additional bureaucracy and a Command-and-Control approach that is totally unnecessary given the work ethic and devotion of most doctors. The Board of the Ontario Medical Association unanimously condemned the actions of the Government of Ontario and the Minister of Health and Long Term Care.

Hard upon this, now consider the federal government’s “Take it or leave it” offer to the provinces of an “increase” of $11.5 billion for home care and mental health. That’s meant to be an investment over the next TEN YEARS, for all Canadians. That’s an investment of about $300 for every Canadian. This is not more than a week’s worth of home care or 2 sessions with a clinical psychologist. Dr. Granger Avery, the President of the Canadian Medical Association, said, “The Groundhog Day-type discussions where political leaders bat around percentages and figures at meetings in hotels have to stop.”

Really, Ministers, doctors would like to be able to have a real discussion about a health care proposal that you introduce that does not require the use of quotation marks to alert the public to the fact that health ministers and doctors speak a different language, especially where money and patient needs are concerned.

As a physician, I would like to think that there is an opportunity to discuss why these proposals will not meet the needs of my practice. As a patient, I want analysis that demonstrates to me that the investment of my money has been careful and methodical and that investments are linked to outcomes that both my doctors and the government agree on. As a citizen, it is distressing to be a bystander to this grandstanding by legislators. This is people’s healthcare. You are governing. Please consider your proposals with the seriousness they deserve. Please talk with me, not at me.

The Auditor General, The Minister of Health and The OMA

In the next week or so, there will be so much detailed analysis of the Auditor General’s Report on Physician Billing in Ontario that the small observation I am making here today here will be lost. As I reviewed the 57 pages, the details and references convinced me that the analysis had been seriously undertaken.

Some conclusions seemed quite inaccurate to me, e.g. “Our review of Ministry data noted that for the 2014/15 fiscal year, each physician in a Family Health Organization group worked an average of 3.4 days per week, and each Family Health Group physician worked an average of four days per week.” Most of my colleagues in these models work at least a five-day week.

Other conclusions really did reflect what I have heard from colleagues in all parts of the province, e.g. “A large number of the physicians who responded to our survey emphasized that patients’ demands are the driving force behind health-care costs. Many suggested that patient accountability is required to ensure that only necessary services or procedures are performed and costs are not duplicated.”

I want to focus, however, on one observation about the 14 recommendations, or specifically the Ministry’s response to them. Ten of the 14 recommendations require the Ministry to work with the Ontario Medical Association and, in each case, the Ministry confirms this. The recommendations are simple enough as statements but they are complex with respect to the knowledge and understanding of physicians’ practices that will be required to implement them.

Here is that common theme running through the Ministry’s responses:

“Adjustments to the capitation rate will require the Ministry to engage with the Ontario Medical Association (OMA) through the negotiations and consultation processes of the Ontario Medical Association Representation Rights and Joint Negotiation and Dispute Resolution Agreement (OMA Representation Rights Agreement).”

“Contract amendments, including minimum number of regular hours and consequences for not meeting contract requirements, will require the Ministry to engage with the OMA through the negotiations and consultation processes of the OMA Representation Rights Agreement.”

“Enabling these recommendations would require contract amendments and will require the Ministry to engage with the OMA through the negotiations and consultation processes of the OMA Representation Rights Agreement.”

The problem for the Minister of Health and Long-Term Care is that his preferred way of “engaging” with the Ontario Medical Association and Ontario physicians for the past two years has been through unilateral imposition of cuts and contract amendments. With Bill 41 as the last straw, doctors collectively and the OMA are informing the Minister and the public that working without a contract and being dictated to by legislation do not further a productive relationship.

So the Minister has a problem. By the Ministry’s own admission, 10 of the 14 recommendations in the Auditor General’s Report on Physician Billing will require him to work with his physician partners and the OMA. Over the years, only the Ontario Medical Association has provided realistic ideas about how to implement government recommendations. This is well illustrated in the various examples of real practice situations outlined in the Auditor General’s report. Developing payment models and incentives that improve access for patients is necessary for the health care system to work properly. These models of care promote both a healthy population and a stable, fairly remunerated physician workforce.

Ministers pay attention to the Auditor General’s Reports. I hope the Minister of Health and Long Term Care keeps this report in mind and that he reaches out to the OMA. I hope he does, but I’m not optimistic.

Bleak Midwinter

The holiday season has officially started. I have begun to make a list of the families in my practice that should receive grocery vouchers so that they can afford food for the holidays. I also make a list for the teenagers who are living on their own. I confirm addresses and watch young people’s faces closely so that I can discern whether they are, in fact, housed. I ask them if their housing is safe, looking them right in the eye. I have a list of numbers on the corner of my desk for families or youth to call if they need housing. I have lists of where free holiday dinners are provided and where one can sign up to receive gifts. I am not trained for any of this. In fact, few doctors are trained for this work, but we all do it.  The hardest part of this work is finding a balance between the fear I have about how precarious my patients’ living situations can be and the realization that I have a responsibility to make that situation more secure.

I know there are many who will say that this is not a doctor’s job, but I cannot escape the knowledge that I have that says otherwise. Every doctor I know works for the best for their patients even when the best has nothing to do with pathology, physiology or medicines. Every doctor I know asks their patients questions about their income and work and family life.

The sharp contrast between the glittery mall displays and the realities of many lives is especially evident at this time of year.  While so many are focused on what they want the holiday to be, others are thinking of what they need so that the holiday is bearable. The impact of this contrast on mental health is significant.

At a time of year when family is glorified, the difficulties in one’s own family become highlighted. The support of family members is known to be a factor in good health, but how many people do you know who dread the “family” events that come with the holidays? How many of those events end much differently than sitcoms would have us think? Many of the youth I see live in care. Some will be preparing for a visit with family of one kind or another. Some will have days or even a week with their family. Helping youth stay realistic about these visits and the holidays is very difficult for those of us who care for these youth.

I am always most concerned about the youth who do not have a family to visit. Most people around them will be planning a visit and excitedly buying and wrapping gifts and planning travel. The youth without a family will be sharing their Christmas lists with a youth worker or social worker. You will receive gifts, often thoughtful gifts of things you want, but you will not have what you really want which is love, true affection from someone who has known you all your life and is happy for just being able to hang out with you. As a psychiatrist, I could point out the link between “hanging out” and endorphins but I think this just serves to distance us from the feelings. If you can understand what a young person with no family is feeling, you know that this feeling is not good for someone’s mental health.

As a physician, I always take some time off in November or early December to prepare emotionally for the holiday season, whose starkness is so evident in psychiatry. Then I come back to work ready to spend the next month social determinants of health.

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86 Doctors

This past month, 86 doctors from across Ontario have received the devastating news that their practices are being assessed by the College of Physicians and Surgeons of Ontario because of the extent of their opioid prescribing. No patient complaint was made against them but they are all now in the process of preparing their patient records and their offices for the assessment.

I have had a complaint to the College made against me by a former patient. I recall receiving the letter regarding the complaint and how anxious I was as I read it. No matter how effectively we work, or how thorough we are, we all feel as though complaints to the College threaten our career and our livelihood. The period of investigation is stressful and it is difficult to focus on continuing to do a good job with other patients while an investigation is ongoing. I know enough readers have had a complaint made against them to understand the stress I’m describing.

Who are these 86 doctors? From reading the coverage of this story in various news outlets, one is lead to believe that the prescribers are at fault. The Minister of Health describes that the doses some are prescribing “are equivalent to roughly 150 Tylenol 3’s being consumed in one day”. While this may be the equivalent, I doubt that this is actually the form in which these painkillers are being used.

As a psychiatrist, I absolutely agree that we have a serious problem across Canada because of addiction to opioids. As a psychiatrist who treats adolescents, I know that the access to these drugs is so easy that addiction to them is becoming more and more problematic. At the same time, I am concerned for the physicians who are prescribing painkillers in justifiably high doses to patients whose care depends upon them.

So, again, who are the doctors whose patients legitimately require high doses of opioids? Palliative patients, patients with serious addictions who are being weaned off opioids and chronic pain patients can all reasonably receive high doses of opioid drugs. These are all patients with special needs and there are very few doctors in Ontario with the expertise to look after them. We know there are long waits for palliative care. Many of those being weaned of opioids because of addiction problems are in shelters or prisons. Both shelters and prisons are underserved, with vulnerable populations and it is stressful to work in these environments. Chronic pain conditions are also difficult to manage and many doctors do not want this work.

A complaint was made against me to the College by a parent who was unhappy with a report I wrote for the Family Court that was unfavourable toward them having custody of their children. My response to the complaint was that I stopped doing any work where my opinion might be sought for court purposes. Imagine what it would mean if these 86 doctors stopped the work they are doing. What if they stopped doing palliative care, or work with the homeless or people in prison, or those experiencing chronic pain?

The stress of a College complaint is difficult, just one more thing to cope with in a practice of patients with special needs and in which there are few colleagues. I can understand giving up this work over time to avoid these stressors, as much as I know we desperately need these doctors who do this work.

In this special circumstance, where we do need to understand opioid prescribing and opioid addiction better, might there not have been a better way to find out more about those who prescribe high doses of opioids? To find out more about their patients? I am not saying that the College is insensitive or arbitrary. I do think the College of Physicians and Surgeons of Ontario works very hard to take an educational approach. I am saying, however, that good doctors, who strive to provide the best care to the point of perfectionism, become so anxious when they hear from the college that it affects their sense of wellbeing. A person can only put up with this for so long before they do give up, and it is some of the most vulnerable patients who will be affected.