Disenfranchised

I am feeling disappointed with the voting process for the Canadian Medical Association President-Elect Nominee from Ontario. A few people on Twitter are saying it only took them 5 minutes, but they clearly had all the right numbers and user names and passwords together at exactly the moment that they decided to vote. I had a spare ten minutes on a Wednesday evening before a teleconference started, clearly had none of the right details and ended up having to vote last Saturday when I could go through the information more carefully.

Some of the information that was most helpful came from a Past Ontario Medical Association President who had sent an email encouraging people to vote and from a friend I called incidentally about something completely different. I did vote but it took about half an hour, not including any time on the phone with friends. I did hear from two candidates that relatively few people had voted and so I started calling the list of people I had been encouraging to vote. I coached five people through the process as they were keen and I think every vote is really going to count in this election. I did have to coach them around the pitfalls I had encountered, and did return to the former OMA President’s email for the solution to a problem different from the one I had encountered.

I will be very interested to know what the turnout is in both the OMA and CMA elections that are currently underway. I know from the personal experience of having run in both OMA and CMA elections that the turnout is usually under 20% in both, less than the turnout in most Canadian municipal elections. Turnout in Canadian municipal elections varies although this work from the University of Waterloo outlines a rate of 35% in Vancouver, which is the lowest among several Canadian cities. The turnout in the last federal election was high – 68.49%.

The University of Waterloo article does mention that online and telephone voting usually increases voter turnout. This is the Canadian Medical Association’s first completely online election for President-Elect Nominee in Ontario so it will be interesting to see whether the voter turnout is increased. After my experience, I am guessing that this will not be the case. If I am correct, and the voter turnout is very low, I will be interested to learn from CMA how close they came to the target they set for voter turnout. By the same token, I will also be interested in seeing whether, in its second year of primarily electronic balloting, the OMA is managing better turnout rates. I have found the OMA system to be more straightforward, but this is not everyone’s experience.

I am going through this long, likely boring story of voting in the CMA election to stress that we must hold all entities accountable when they claim loftily that they are democratic without ever establishing exactly how they ensure that anyone who is eligible to vote can easily do so. Turnouts under 30% don’t suggest great accessibility to one’s franchise, but I could not find any target for acceptable voter turnout by any association or elected jurisdiction. Which suggests…what? They don’t care?? They think that low turnout is mostly the electorate’s problem??

Even countries as proud of their democracy as the United States have had to implement laws to ensure that African-Americans have fair access to their franchise, but not everyone follows these laws as the American Civil Liberties Union will attest.

As a citizen, I have volunteered in elections of every kind, in the belief that by doing so, I am doing everything I can to promote the democracies that govern me. I do this in all kinds of uncomfortable circumstances grateful that I do not face censure or death as many do around the world in jurisdictions where democracy is less secure. I even consider this expression of concern regarding the CMA’s election process to be part and parcel of my duty as a member of that organization. So I will ask my CMA representatives: Do you care that the voter turnout was so low and what specifically are you doing about it? I just hope the response does not leave me feeling like P. J. O’Rourke, who famously said: “Don’t Vote. It Just Encourages the Bastards.”

Photo credit

 

How to Legalize Marijuana

My interview on CBC’s The House had such a positive reception that I wanted to follow up with a short essay summarizing most physicians’ recommendations for legalizing marijuana. My own perspective is that of a psychiatrist whose patients are all adolescents and young adults. This means I am concerned about the short-term impact of marijuana intoxication in the young people that I see, but I am even more worried about the long-term impact of cannabis on the developing brain as well as the links between cannabis use and psychotic illnesses.

Most physicians hope that the federal government will approach the legalization of marijuana emphasizing public health concerns as the most important consideration in the drafting of legislation. There are also law enforcement and government revenue aspects of the legislation but in jurisdictions where these considerations were emphasized, health outcomes were affected. Doctors in Canada – and Canadians in general – will find that negative health outcomes will eliminate any possible benefits to legalizing and regulating marijuana.

The government’s vision is to have marijuana legally available for non-medicinal purposes by Canada Day 2018. For the implementation to fully consider the public health implications, the government can look to its experience with the legalization and regulation of tobacco and alcohol. There are lessons to be learned from this experience from a public health perspective and I hope Canadians can benefit from that experience. We can also learn from those countries and jurisdictions that have already legalized marijuana. Also, now is the time to set up an evaluation and research agenda to ensure that we continue to learn from our experience with legalizing marijuana.

Some of the main health concerns with marijuana are related to its impact on the developing brain. The brain continues to develop until age 25 and there is significant evidence that cannabis use interferes with brain development. While it would be ideal if the minimum age to purchase marijuana could be 25, Young Canadians are already using twice as much marijuana as any other age group in Canada. Young Canadians also have a higher rate of cannabis use than youth in any other G8 country. With use being this high (20% of Canadians aged 16-24), it is more realistic to focus on reducing cannabis use to the extent that is possible. The Canadian Medical Association recommends setting a national standard where minimum legal age for purchasing marijuana would be 21, but with restricted strength and purchasing limits until age 25.

As well as brain development, child psychiatrists have also noticed increased prevalence of psychotic symptoms in young people using marijuana. We notice that psychotic symptoms emerge at a younger age for those with a predisposition for these conditions who use marijuana. We also notice that cannabis use is associated with the more serious chronic symptoms of schizophrenia.

Many physicians are also concerned that that rigorous research has never been applied to whether marijuana has any medicinal value. Marijuana has been available for medicinal purposes in Canada for many years, but there are few, if any, studies confirming its efficacy. Given the health risks, is it not time to insist on research to determine whether medicinal marijuana is effective?

Finally, one of the most important public health impacts will be related to the consequences of driving while intoxicated.  One’s capacity to safely operate a motor vehicle after using marijuana can be affected for as long as 6 hours after use. There is no currently no adequate way to identify or evaluate whether a driver is under the influence of cannabis. A method to evaluate intoxication must be developed before legalization. In this regard, the experience of Colorado should inform Canadian legislators. This excellent review outlines the increase in traffic accidents and Emergency Room visits since marijuana was legalized. Traffic accidents are one concerns but there are others. Colorado legislation was focused primarily on the revenue generating aspects of marijuana legalization. The negative health outcomes should be a cautionary tale for Canadians.

I have focused on those aspects of marijuana legalization that are most important in my practice but the Canadian Medical Association prepared a detailed submission for the Government of Canada Task Force on Marijuana Legalization and Regulation. Canadian doctors and the Canadian Medical Association are extremely concerned about this legislation. Great effort has been taken to alert the federal government to the risks involved in legalizing marijuana. I mentioned earlier that I wished the legal age to purchase marijuana could be 25. I can see how unrealistic this is, given how much marijuana young Canadians use right now, when it is not legal. After the fact of negative health outcomes from legal tobacco and alcohol, Canadian governments have had to launch massive public health and education campaigns. It would be good to roll these out now, in the hope that we can avoid some of the negative health outcomes doctors know are coming.

Benjamin Franklin made what must be one of the first public health statements in America. We can remember this as marijuana legislation moves forward, even if Colorado didn’t:

“An ounce of prevention is worth a pound of cure.”

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.

Medical Professionalism II

I read this op-ed by Dr. Louis Francescutti on Tuesday evening after a long day. Perhaps it was because I had spent the day trying to convince adolescents’ parents that scolding never works, perhaps this tone still grates on me since I was an adolescent, but whatever the reason, Dr. Francescutti’s nagging that my work was not good enough and I wasn’t accountable set me off.

I spend my days trying to convince youth that my suggestions are not meant to ruin their lives, but rather to treat their auditory hallucinations or their anxiety or their depression. I cajole, beg, coax, reason, flatter, give articles, demonstrate apps – in short, I’ll do anything to get my young patients to do what they must to be better. When they are most despondent, I say, “We’ll never give up. We’re going to keep going until you feel better.” Persistence is my best and worst quality.

There is one thing, however, that I never do. I never scold people, never lecture. I learned when I was 23 years old and just starting my residency in Psychiatry that scolding doesn’t work to change anyone. The above rant is my way of commenting that the tone of Dr. Francescutti’s opinion article on medical professionalism did not open my mind to his overall message that greater accountability is needed in the medical profession.

Sometimes a writer will seek to make a point by being provocative. The kindest readers believed this to be true of Dr. Francescutti. Again, my experience has taught me to strive to be persuasive and to find the points of consensus among people who might otherwise disagree. The research in my discipline, psychiatry, shows that this model works best in circumstances where there is conflict or tension and where the goal is to help one person see another point of view, often a hurtful point of view.

In many parts of Canada today, provincial governments are scolding doctors in much the same manner as Dr. Francescutti scolded us. Some commentators suggested that doctors are overly sensitive but mostly, I believe, we feel hurt. The partner we want to have in transforming the healthcare system, the government, has rejected all of our suggestions and, since it can, has decided it is just going to set up the system as they think is best. I can certainly attest that, in travelling around Ontario talking to doctors in every specialty, of every age, after I hear how angry doctors are, I do hear how hurt they are that their work is so underappreciated and undervalued.

When the atmosphere within medicine is tense, filled with mistrust and hurt, tone is even more important and I believe that Dr. Francescutti overlooked this in his comments. In times like these, people need their leaders to say,

“Remember who you are and what you do for your patients.”

“Yes, we need to do more, but don’t you always do more?”

When you’re encouraged, no matter how bad things are, you can say, “I didn’t quite get that, Dr. Francescutti. Could you say it again, maybe a bit differently? I think you’re making some good points.”

Health care transformation should be a dialogue: What do you think we need to do?

Physician Activism: Is It Worth It?

In the last two or three months, I have gotten fed up with waiting for “something to happen” in the Cold War between the Ontario Medical Association (OMA) and the Ministry of Health and Long Term Care in Ontario. I know perfectly well that this is a marathon and not a sprint, but in endurance challenges of any kind it is usual to check your position and “test the endurance” of other players and so I, personally, have begun to do this.

One of my actions was to develop three motions for the Emerging Issues debate at last month’s Canadian Medical Association General Council in Halifax. These were the motions:

  1. The Canadian Medical Association insists that provincial/territorial governments should fund all necessary health care.
  2. The Canadian Medical Association stands against governments undertaking unilateral action in lieu of a negotiated agreement with physicians.
  3. The Canadian Medical Association supports the Ontario Medical Association’s request for the inclusion of a binding dispute resolution mechanism in its contract negotiations with the Government of Ontario.

Here is a link to the CMA coverage of the motions.

These motions had very strong support and I tweeted out the news which caused several to ask: What difference does this make? What can CMA do?

It’s fair to ask this question but the answer takes more than 140 characters to answer.

The first difference it makes is that these motions establish a national policy at the Canadian Medical Association that provincial and territorial governments should fund all necessary growth in health care and not pass off their responsibility under the Canada Health Act. I have written about this previously several months ago: https://drgailbeck.com/2015/04/19/getting-blood-from-a-stone/ Governments are now being asked to fund pharmacare and psychotherapy at a time when they are already not meeting their responsibilities for funding hospitals and physicians. This first motion establishes the policy for our national association that governments should meet their existing responsibilities.

The second motion means that the Canadian Medical Association will stand against any government abandoning negotiated agreements with physicians in favour of unilateral action. We are in difficulty because of such action in Ontario, but our Quebec colleagues are facing an even worse fate from their physician health minister. http://www.assnat.qc.ca/en/travaux-parlementaires/projets-loi/projet-loi-20-41-1.html

In addition, since most jurisdictions and physician bargaining units in Canada already have access to a binding dispute resolution mechanism, the final motion confirms the need for Ontario doctors to have this as well.

As well as setting CMA policy, these motions did also provide an opportunity to highlight Ontario’s doctors’ situation and Dr. Toth, OMA President, had a number of media calls in response to the motions.

These are small pieces of work, to be sure, but in working on these motions, I was doing something. To use the marathon analogy, I tested the field and the interest and have finally had some people get in touch with me about the OMA’s situation and the impact the cuts are having. Maybe if I keep pushing, a few others will also begin to push and maybe we’ll start to build some momentum. I am not the only person pushing. In fact, most members of the OMA Board and a few others as well are using every means at their disposal to bring attention to the impact of the government’s cuts on healthcare. The OMA itself continues with a media campaign that also seems to be going unnoticed, but it is there. These days, it feels as though we are a very small group, unable to garner much attention, but we are committed and all of us believe that change is possible.

I am doing what I can in other ways also. I am going to continue to meet with doctors, meet with MPP’s, bring motions and write about these cuts. Maybe it is all useless, but I will continue with these actions until enough people begin to notice. I welcome anyone who wants to help. Leave me a message here and I’ll get in touch.

Is anyone out there?

“Never doubt that a small group of thoughtful, committed people can change the world. Indeed it is the only thing that ever has.” Margaret Mead