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.

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.

Bill 41 and Hospital Physicians

This installment on Bill 41 comes after a longer review of the Ontario Hospital Association’s backgrounder on Bill 210 released earlier this year. They have not published anything specific to Bill 41.

My personal concern about Bill 41 is based on my alarm over the extraordinary amount of control the government feels it needs over what doctors, agencies, hospitals and LHINs are trying to do locally to look after patients. This is the fourth time I have written about Bill 41 and the longer I look the more alarmed I become. What on earth makes the Toronto-based Ministry of Health and Long Term Care (MOHLTC) believe it has the answers to how health care must be organized in regions so different and so remote from each other that many of the citizens in one have never been to another?

The concerns about Bill 41 for doctors in hospitals are around these parts of Bill 41:

1.       Expanded Ministerial Authority over Hospitals

2.       LHIN Functions and Governance

3.       Home and Community Care

4.       Public Health

Let’s begin with the Expansion of the Minister’s authority over hospitals. Any time the government feels a need to expand its legal authority, it’s important to examine why their moral authority has not been effective in driving change. What Bill 41 really does is allow the Minister to override the decisions of local hospital boards, setting directives and standards. Having served on my hospital’s board in my capacity as President of the Medical Staff Association, I can state that our hospitals in Ontario are well-governed, put patients first and that their boards are populated by local experts who have the best interests of the patients and population at heart. The Minister has not given one reason why he needs to interfere with this. The doctors in a hospital can presently raise concerns with a Board through the Chief of Medical Staff or the President of the Medical Staff and their opinions are sought out and seriously considered. This is very different from doctors’ experience with government. Further authority for the Minister over hospitals is not good for either hospitals or the physicians who work in them.

Secondly, let’s consider how the changes in Local Health Integration Network’s (LHIN) functions and governance could affect hospital physicians. The bill expands the list of health service providers to include family health teams, hospices and “any other person or entity set out in regulations”. Some family health teams and hospices are hospital-based and all of those are staffed by physicians, so these doctors will be affected. In fact, it is important to remember how many primary care physicians provide hospital services. We tend to think of consultants being affiliated with hospitals but many hospital emergency rooms, operating rooms, wards and other services depend on family physicians to provide care. Many Emergency Rooms in smaller communities only remain open because their dedicated medical staff provide extra coverage. They don’t need Bill 41 to tell them what needs to happen.

What I find most concerning about this section on LHIN functions and governance is that the Health Professional Advisory Committee, which all LHINs must have at present, becomes discretionary under Bill 41. When LHINs were first introduced by the Liberals in 2006, the Health Professionals Advisory Committees were criticized as providing too little direct physician input into local health decisions. Now LHINs will have an option of excluding this group altogether. Why is there this need to exclude doctors from all healthcare decision-making?

As for home and community care and public health, all physicians must access these services for their patients and this includes hospital physicians. As a physician, I depend on community services for my most disabled patients. These services need more front line staff and a better capacity to deliver service in a timely fashion, not this extra bureaucracy that will tie up caregivers with paperwork.

Most importantly to all doctors who work in hospitals, all of us do see ourselves as being community physicians as well – after all, the hospitals where we work are in the communities where we live and are part of the fabric of our towns and cities. Hospitals and their medical staff contribute to the prosperity of towns and cities. Doctors care deeply about the prosperity of their communities and the quality of care provided by hospitals. Bill 41, with its need to bring greater control over health and health care decisions, is insulting doctors by giving the impression that these measures are necessary. The doctors in my community are working very hard to ensure that our care addresses patients’ needs. Many of us are volunteers on hospital boards, hospital committees, LHIN committees and Health Professional Advisory Committees. Is the Minister suggesting that we should stop? That’s what it feels like.

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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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