Driving and Marijuana

With the legalization of marijuana fast approaching (The Government of Canada is now saying “sometime this summer”), it was only a matter of time until one of my patients asked this question:

“Dr. Beck, how much marijuana will I be able to use and still drive?”

“I didn’t think you were driving yet.”

“I’m not driving officially, but I’m going to get my G1.”

“So, you don’t even have a G1 and you’ll be too young to buy marijuana legally, but you want to know how much you can use and still be able to drive. Is that what you’re asking me?”

“Well, when you say it that way, it makes it sound like I shouldn’t consider this at all, but I’d like to know.”

In fairness to this young person, I should say that both youth and parents are asking me similar questions, so I decided to see what I could learn about driving under the influence of cannabis. For the purposes of preparing this short review, I used three main references. One reference is a comprehensive report entitled Developing Science-Based Per-Se Limits for Driving under the Influence of Cannabis: Findings and Recommendations of an Expert Panel. The report was written in 2005 and includes a thorough summary of the Empirical Research on cannabis and driving. I checked with the Medical Librarian at my hospital to see whether they could find a more recent and as comprehensive report. Since they could not, I highly recommend this excellent, comprehensive reference.

I also reviewed the research of the American Automobile Association and the Canadian Automobile Association which, while not as comprehensive, is much more understandable for most readers. I will use these a references for most people who ask me for information.

Finally, I regularly review the Government of Canada and the Government of Ontario websites for updates on the legalization of cannabis. The Government of Ontario has determined that the Ontario Provincial Police will use Oral Fluid Screening Devices for roadside testing of cannabis. There are some concerns regarding the reliability of the devices and, since the Expert Panel Report recommended blood levels only as a means of measuring cannabis levels, it seems that cannabis will be introduced without clear guidelines regarding impairment comparable to Blood Alcohol Levels.

When discussing driving safety while using any substances with parents and youth, I always stress that a person should never drive if they feel at all affected by what they have ingested. As most people know, the extent to which a person can feel affected by a substance they ingest can vary widely from person to person, but, if an individual is being honest with themselves, this can be a very reasonable guideline.

For those wanting something more precise related to cannabis use, I did determine a straightforward guideline from the information in the Expert Panel Report. The report reviewed the results of all the epidemiological studies related to driving and cannabis use and performed a meta-analysis of the experimental studies.

In reviewing all the studies, the panel reminded the reader that there are 3 phases of impairment due to cannabis use. There is an acute phase, during the first 60 minutes following smoking cannabis. Then there is a post-acute phase that presents 60-150 minutes after use. There is, finally, a residual phase, occurring 150 minutes after ingestion. The panel members concluded that most studies showed that the impact on driving skills is minimal during the residual phase. This means that, depending on the amount of cannabis smoked, most people will no longer be affected 3-4 hours after smoking 20 mg of cannabis. This is the basis of the guideline I am providing: Don’t drive for 3-4 hours after smoking cannabis, depending on the dose. (Note: The studies also showed that there are differences in the timing of impairment after smoking cannabis, as compared with oral ingestion. Impairment relation to oral ingestion of cannabis peaks 2-3 hours after consumption, while impairment after smoking cannabis peaks at one hour.)

I like this guideline because it is clear and straightforward, although I am also reminding the young adults in my practice that most of them would never go out for an evening during which they might drink at all without a designated driver. My own practice suggests that, as far as alcohol is concerned, most youth I know would never drink and drive. Why not also have the same “designated driver” system when using cannabis?

As I review these studies and reports in conjunction with the information being provided by the federal government, I continue to be concerned about the lack of foresight in legalizing cannabis in Canada. It seems to me that the amount of time needed to ensure the safe legalization of cannabis might have been more accurately predicted. If the timing was not well-managed, can we really be sure that other aspects of legalization will be handled safely?

(photo credit)

Guest Blog: Dr. Cargill and Dan’s Law

For the past nine months, I have been visiting my sister who is dying in Nova Scotia. This experience has truly sensitized me to the needs of those who need palliative care, and I now appreciate how much I will want to be able to control how and where my life ends. But this is not always possible, as Palliative Care physician Dr. Darren Cargill found out while caring for Dan, a patient who had moved to Ontario from Alberta. Dan’s story is very moving, and it underlines some of the inhumanity in our disjointed healthcare system. Dr. Cargill confronted this inhumanity on his patient’s behalf, and that is an even more inspiring story.

I asked him as a guest blogger to speak about his advocacy on behalf of Dan, advocacy that has resulted in the introduction of Bill 54 into the Ontario Legislature. Here is what he had to say:

“Bill 54, introduced by MPP Lisa Gretzky and which was debated and passed second reading on November 17th, 2016, provides much needed support for patients and their families. Canadians who move or return to Ontario and require palliative care or home care should not be subject to the typical three-month wait to be eligible for OHIP services.
The Bill carries the support of the Ontario Medical Association on behalf of its 34,000 physicians and medical students.
The issue came to light for me when a patient, Dan Duma, was denied home care services upon returning to Ontario from Alberta. Dan was dying of cancer with a life expectancy of less than three-months. Dan’s Law prevents future patients, families and caregivers from experiencing unnecessary hardship as a result of this lack of access to needed care.
As a doctor, I know that there is no medical justification for the wait period and I believe that, especially in these circumstances, we should afford Canadians and permanent residents the right to die with dignity. The benefits of home and palliative care are not only medical – they serve to support family members and caregivers.
The benefits of timely care include avoiding potential medical complications of delayed care and the associated significant human and financial costs arising from these complications.
Bill 54 has passed second reading and was sent to the Standing Committee on Justice Policy. This bill needs to be passed before the provincial election. I am asking that you write to your MPP and ask that Dan’s law be passed.”

Why would a person have to move from one Canadian province to another if they were dying? We all know the answer to this. They would move to be closer to family members. Why should they be denied the benefits of palliative care or home care? Please send an email or letter to your MPP and ask them to move Bill 54 forward. No one should ever be denied care in Canada because they moved from one province to another to be closer to family.

You can contact your MPP in Ontario using this list. If you are a physician in Ontario, please support this work. You can find a template letter under Advocacy on the OMA website. You do not have to say much, just tell them to get Dan’s Law passed before the election.

You can tell from how he wrote those few words above that Dr. Cargill is a doctor who feels that part of his work is getting all the support his patients need, even when that requires changing the law. Think about yourself or your own family. If you, or a loved one was very ill and had to move to be closer to the people who love you, so that they could be with you and look after you, is it reasonable that your health care would be compromised? Of course not! Thank you to Dr. Darren Cargill of Windsor for working so hard to change an unreasonable situation.

Photo credit

 

Not Just Any Village

In recent months, I have come to learn more and more about the difficulties indigenous youth have in obtaining mental health services. In part, this is because local, provincial and federal news reports are calling attention to these difficulties but I am also very much aware of the needs of these young people in my own community and practice.

It is especially distressing that, despite the goodwill of governments and their financial investment, all the measures that have been taken seem to have no impact. How can this be?

I have come to understand this only in the context of being a mother myself and it is only using this reference point that I can make sense of why our efforts have been so ineffective. Let me see if this helps you to understand what is missing.

Imagine that your child has serious mental health problems. She is twelve years old and started using substances like cannabis, or alcohol, or solvents. (I have seen indigenous youth who started using substances, especially solvents, as young as seven years old.) School is a struggle and because of this, the child feels hopeless about the future. Perhaps as a parent, you can understand this because you were in the same situation at her age. You are desperate for your child to get help and so you agree that she should travel hundreds of miles away from home to get that help. You agree to this even though you will miss her desperately, and worry about her all day, every day. You know she is anxious and will cry because she misses you and her family, but you know that you cannot travel with her because there are other children to care for, or your job, or even because you yourself do not have the emotional strength to support her. Who cannot relate to the desperation of this situation? Of this parent? Of this child?

The research evidence is overwhelming that children’s health depends on family support. It takes the first year of our life to be able to walk. It takes us until we are two to utter a few words. We begin to have the skills to read, and write, and do math around age five. The evidence says that our enormous brains can take until age 25 to fully develop. We clearly need personal support to grow and develop and every culture relies on families to provide that support. When we are unwell, we need that support even more.

How do we expect these children to heal when we send them away from their families? If we must do this, could we not at least set up those sophisticated telehealth networks and facetime for parents and children and grandparents and brothers and sisters to stay in touch? “It takes a village to raise a child” is an African proverb that recognizes the universal truth that we need our families and kin – our village.

When I am having a hard day, I will often count my blessings and the blessings I remember first are the people of my personal village: my children and husband and family and friends.

Do we really believe that indigenous youth (or any youth) will become stronger mentally away from their families? Have we really learned nothing from the experience of those sent away to residential schools? Are we really not listening?

If those African philosophers will permit, I do have one slight modification to their proverb. I agree that it takes a village to raise a child, but not just any village will do. Each child deserves the support of their own village: their own family, their own friends, their own people.

(Photo credit: Family Ties sculpture by Kevin Barrett)

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?

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.

Bill 41 – What about Specialists?

Here is my last question about Bill 41 before it goes to Committee: Once Minister Hoskins finishes bringing family doctors “into line”, what has he got planned for specialists? One might get the impression from the government’s reasons for introducing Bill 41 that family doctors are sitting around their offices eating bonbons all day but, really, that just isn’t the case.  Watch the activity in your family doctor’s office while you’re waiting for your appointment and you’ll realize that they are run off their feet.

But access is also problematic in the offices of community specialists, and especially the specialists in medical and pediatric and mental health specialty care. Internal medicine specialists, pediatricians and psychiatrists are the system’s experts in chronic disease management. These specialists look after babies with failure to thrive, children with diabetes, youth with schizophrenia, adults with chronic obstructive lung disease and the elderly with every chronic condition imaginable. We are the consultants family physicians seek out when a patient’s chronic illness suddenly becomes acute.

In my practice, I hear from family doctors when a young person with major depressive disorder begins to feel suicidal after months or years of being symptom-free on the correct medication and successful cognitive behavior therapy. Because I work in a hospital setting with a full team of clinical psychologists, social workers, psychiatric nurses, recreation therapists, occupational therapists and child and youth workers, my youth program has no waiting list. We can bring youth in quickly and settle what is happening, or work on it with a young person and their family, offering a limited choice of treatments.

A psychiatrist in a community setting, however, is in a very different situation. Because they have no team and limited access to community resources, that specialist is often monitoring highly complex patients performing to the best of their ability all the functions of a team working with the family doctor. This is an essential service in medicine since these are often the only people available to provide therapy to those who could otherwise not afford it. Every community medical specialist performs similar services in their own specialty areas and benefits many patients. These doctors are valued by patients especially because the practice setting is “private” and can sometimes afford a level of individualized care that might not be available in a hospital setting.

The reasons a specialist works in the community and not in a hospital setting are varied. I worked in private practice when it was impossible for me to be on call. My three children were born within two and a half years and, for the years I was a single parent, it would have been impossible, of course, to leave them to assess a patient in the emergency room.  For all the years that I was in private practice in Ottawa, my patients had my home number in case there was a problem. This is true of many of the community specialists that I know, and many of them do provide call in community hospitals. In small communities, they are often the only expert in their specialty that the Emergency Room physicians can access. These doctors are vital to the health care system that patients depend on.

For the last four years, the Government seems not to have considered community medical specialists at all – which means that the patients these specialists care have also been overlooked by the government. Many medical specialists have seen the resources some primary care practices have been able to access and wondered whether the government might ever consider resources for their patients.

Dialogue between doctors and the government does not exist, however, except on the government’s terms. We have watched as the Government of Ontario cut off resources and even began to limit entry into certain family practice groups. Despite the increased access family doctors have provided to Ontario patients, it has not been enough to satisfy the government and so they have begun to unilaterally impose the organization they want through cuts to fees and now legislation via Bill 41.

Bill 41 focuses everyone’s attention on primary care, and doctors and patients depend on family physicians to be the stewards of patients’ overall care. When the government begins to realize that patients also need more specialist care for their chronic diseases, it seems likely that they will also try to shape how community specialists practice. When that happens, can the individualized, patient-centred care that these doctors provide survive? Bill 41 tells us both patients and physicians come after administrative concerns.

The system of community consultants isn’t perfect, but patients value it. Specialists have ideas about how to improve community care, but is anyone listening?

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